



Class TK C 4 (o 

Book AJ4£ 



T 



PRACTICE OF MEDICINE. 



TREATISE 



PEACTICE OF MEDICINE. 



BY 



EDWIN R. MAXSON, M. D., 

FORMERLY LECTURER ON THE INSTITUTES AND PRACTICE OF MEDICINE IN THE 
GENEVA MEDICAL COLLEGE. 




/ 



PHILADELPHIA: 
LINDSAY & BLAKISTON, 



1861. 
is 






Entered according to Act of Congress, in the year 1861, 

BY EDWIN R. MAXSON, M. D., 

In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



HENRY B. ASHMEAD, BOOK AND JOB PRINTER, 
Xos. 1102 and 1104 Sansom Street 



LC Control Number 




tmp96 028699 



PREFACE 



This "Work, which has been written during the past two 
years, has been under contemplation for several years; and 
consists in part of a course of lectures delivered in the Geneva 
Medical College. It has been arranged and prepared for pub- 
lication, in part from an earnest solicitation of members of 
the medical class, for whose opinion I entertain the highest 
respect. 

It will be seen that I have glanced at the anatomy and 
physiology as I have taken up the diseases peculiar to each part 
of the human system. This I have done in part to make the work 
more valuable to those practitioners of medicine who have not 
time to review anatomy and physiology ; but more especially to 
keep the mind of the reader fixed on the diseased part, and its 
conditions ; thus rendering the work not only more valuable, but 
I trust more interesting. 

I have attempted to draw up the work without even the shadow 
of empiricism, by taking the human system in health as the 
standard; and then noting the deviations from that standard, 



VI PREFACE. 

constituting the various morbid conditions or diseases. By taking 
this course I have been enabled to arrive at clear indications of 
treatment, from direct pathological conditions, for every prescrip- 
tion which I have made. 

This course by no means precludes the benefit of experience in 
the use of remedies ; as remedies which are indicated from patho- 
logical conditions are always those which experience finds the 
most successful. I have preferred, then, to arrive at them in this 
way, rather than empirically, as it tends to lead the mind of the 
student and practitioner of medicine to prescribe for conditions, 
without reference to names. 

Among the remedies which I have suggested, it will be seen 
that I have included the most approved new ones ; among which 
are the valuable preparations of Tilden & Co., and others, which 
are now coming into very general use, with heretofore no work 
on the Practice of Medicine even referring to them. This I trust 
may render the work especially valuable to students and practi- 
tioners generally. 

While I have attempted to make the work as original as a prac- 
tical treatise on this subject can well be made, I have examined 
carefully the standard works on the Practice of Medicine, and 
especially the Cyclopaedia of Practical Medicine, revised by Pro- 
fessor Dunglison, as well as the more recent valuable works of 
Professors Watson, Dickson, Wood and Bennett. And while I 
have preferred in the main to give my own opinion, it should be 
remembered that I have availed myself of the opinions of these 
and other distinguished authors, with whose observations I have 
carefully compared my own. 

And besides, I have exchanged opinions freely with eminent 
physicians, in order that any new light connected with the Science 
or Practice of Medicine might have due bearing in its arrange- 
ment. 



PREFACE. Vll 

And further, I am under special obligations to Professor John 
William Draper, M.D., LL.D., of the University of New York, 
Professor James Hadley, M.D., of Buffalo, Professor W. D. "Wil- 
son, D.D., of Geneva, and to my preceptor and former partner, 
¥m. V. V. Rosa, A.M., M.D., of Watertowii, K Y.; all of whom 
have kindly made important suggestions in relation to the plan 
aud execution of this work, without being in the least responsible 
for any of its imperfections. 

As the work consists in part of a course of lectures, not designed 
for publication, it is possible that I may in some instances have 
incorporated the ideas of others, even in their own language, 
without giving due credit. If such has been the case, it was 
unintentional on my part, and unavoidable under the circum- 
stances. 

I hope, on the other hand, that I may not be regarded as having 
deviated too widely from the beaten track of my illustrious prede- 
cessors, especially as the Science of Medicine is progressive ; every 
year throwing new light upon our science, which must needs be 
brought in, or have its bearing upon a treatise of this character. 

My professional career thus far has been one of activity, 
having been engaged in an extensive practice, which has 
absorbed nearly all my reasonable waking hours ; during which I 
have gathered up the ideas here incorporated, in a form, I trust, 
however, to be understood. And while I may not have given my 
work the polish of style which it might have received had more 
leisure been afforded me, I confidently believe it will be none the 
less valuable as a practical treatise, for having been arranged and 
written in the midst of an exciting and extensive practice. 

And now, with these few explanations, I throw the work upon 
its own merits, and unqualifiedly offer it to my brethren of the 
medical profession. And if it is found to be an interesting and 
valuable work for the medical student, and as a reference for prac- 



Vlll PREFACE. 

titioners of medicine generally, I shall feel amply repaid for the 
arduous labor which has brought it forth. And, finally, should it 
have the good fortune to reach a second edition, I shall gladly 
incorporate into it anything which may be indicated by the pro- 
gressive advance of Medical Science. 

E. E, MAXSOK 
Geneva, April, 1861. 



CONTENTS 



CHAPTER I. 

OF DISEASE. 

PA 

Section I. — Nature of Disease .... .17 

II. — Causes of Disease ..... 22 

III.— Symptoms of Disease ...... 34 

IV. — Diagnosis of Disease ..... 43 

V. — Treatment of Disease ...... 46 

CHAPTER II. 
OF IRRITATION, CONGESTION AND INFLAMMATION. 

Section I. — Irritation . . . . . . .51 

II. — Congestion ....... 54 

III. — Inflammation ....... 57 

CHAPTER III. 

OF FEVER 

Section I. — The Pathology of Fever . . . ... .67 

II. — The Causes of Fever ..... 78 

III. — The Phenomena of Fever . . . .86 

CHAPTER IV. 

GENERAL FEVERS. 

Section I. — Intermittent Fever ...... 94 

II. — Bilious Remittent Fever ..... 102 

III. — Simple Continued Fever ..... Ill 



CONTENTS. 



Section IV. — Enteric Continued Fever 
V. — Typhus Continued Feyer 
VI. — Yellow Feyer . 
VII.— Plague 
VIII. — Diphtheria 



PAGE 

120 
129 
138 
148 
154 



CHAPTER V. 
EXANTHEMATOUS FEVERS. 



Section I. — Variola — {Small-pox) 
II. — Vaccina — [Cow-pox) . 
III. — Varicella — ( Chicken-pox) 
IV. — Rubeola — [Measles) . 
V. — Scarlatina — ( Scarlet Fever) 
VI. — Erysipelas 
VII. — Purpura . 
VIII. — Glanders — [Equina) 
IX. — Dengue — [Dandy Fever). 





. 


162 


• 


• 


171 

174 


• 


• 


175 

180 


. 


. 


186 




. 


197 


• 


• 


200 
203 



CHAPTER VI. 
GENERAL INFLAMMATORY DISEASES. 



Section I. — Acute Rheumatism 

II. — Chronic Rheumatism 
III. — Gout — [Arthritis) 



206 
212 
216 



CHAPTER VII. 

DISEASES OF THE NERVOUS SYSTEM. 



Section I. — Cephalagia — [Headache) 


224 


II. — Meningitis ..... 


226 


III. — Cerebritis . 


236 


IV. — Tuberculous Meningitis 


240 


V. — Spinal Meningitis . 


244 


VI. — Myelitis ..... 


247 


VII. — Cerebro-spinal Meningitis 


.250 


VIII. — Apoplexy ..... 


254 


IX. — Paralysis . 


261 


X. — Epilepsy .... 


268 



CONTENTS. 


XI 


Section XI. — Catalepsy ..... 


PAGE 

276 


XII. — Chorea — (St. Vitus' s Dance) 


280 


XIII. — Insanity ..... 


283 


XIV. — Mania a Potu — (Delirium Tremens) , 


298 


XT. — Eclampsia — (Convulsions) 


304 


XVI. — Hysteria ...... 


308 


XTII. — Spinal Irritation .... 


313 


XVHT.— Tetanus— {Locked-Jato) .... 


315 


XIX. — Hydrophobia — ( Canine Babies) 


321 


XX. — Neuralgia ...... 


325 


XXI. — Amaurosis , . . . . 


331 


XXII. — Singultus — (Hiccough) .... 


332 



CHAPTER VIII. 



DISEASES OF THE DIGESTIVE SYSTEM. 

Section I. — Stomatitis — (Sore Mouth) 
II. — Glossitis 

III. — Pharyngitis — (Sore Throat) 
IV. — Tonsillitis — ( Quinsy) 
V. — Parotitis — (Mumps) 
VI. — Oesophagitis . 
VII. — Acute Gastritis . 
VIII. — Chronic Gastritis . 
IX. — Cancer of the Stomach 
X. — Peritoneal Enteritis 
XI. — Mucous Enteritis 
XII. — Dysentery — (Bloody Flux) 
XIII. — Malignant Dysentery . 
XIV. — Cancer of the Intestines 
XV. — Acute Peritonitis 
XVI. — Chronic Peritonitis . 
XVII. — Acute Hepatitis 
XVIII. — Chronic Hepatitis . 
XIX.— Splenitis . 
XX. — Dyspepsia — (Indigestion) 
XXI. — Diarrhoea 
XXII. — Cholera Morbus 
XXIII. — Malignant Cholera 
XXIV. — Cholera Infantum . 



334 

338 

339 

342 

344 

345 

346 

349 

351 

354 

356 

359 

363 

366 

367 

370 

372 

377 

379 

381 

385 

388 

390 

394 



Xll 



CONTENTS. 



Section XXV. — Flatulent Colic 
XXVI. — Bilious Colic 
XXVII.— Lead Colic . 
XXVIII. — Intussusception . 
XXIX. — Constipation 
XXX. — Intestinal Worms 
XXXI. — Hemorrhoids — (Piles) 
XXXTI. — Jaundice — (Icterus) 



PAGE 

397 
399 
401 
405 
407 
408 
412 
416 



CHAPTER IX. 

DISEASES OF THE RESPIRATORY SYSTEM. 



Section I. — Auscultation and Percussion . 


420 


II. — Pleuritis — (Pleurisy) . 


428 


III. — Pneumonia — (Pneumonitis) 


432 


IV. — Bilious Pneumonia ..... 


438 


V. — Catarrh ...... 


441 


VI. — Laryngitis . .... 


444 


VII. — Tracheitis — (Rattles) .... 


447 


VIII. — Lartngo-Trachetis — (Croup) 


449 


IX. — Acute Bronchitis ..... 


452 


X. — Chronic Bronchitis ..... 


455 


XI. — Asthma ...... 


458 


XII. — Hooping-Cough — (Pertussis) .... 


461 


XIII. — Tubercular Phthisis — (Consumption) . 


463 


XIV. — Apnoza — (Asphyxia) ..... 


471 


XV. — Pneumothorax ..... 


478 


XVI. — Emphysema ...... 


479 



CHAPTER X. 

DISEASES OF THE CIRCULATORY SYSTEM. 

Section I. — Auscultation of the Heart 

II. — Pericarditis ...... 

III. — Endocarditis ..... 

IV. — Carditis ...... 

V. — Organic Diseases op the Heart 
VI. — Sympathetic Affections of the Heart 
VII. — Neuralgia of the Heart 



481 

488 
493 
496 
498 
506 
511 



CONTENTS. 



Xlll 



Section VIII. — Syncope 
IX. — Arteritis 
X. — Phlebitis 
XI. — Crural Phlebitis 
XII. — Hemorrhage . 
XIII. — Epistaxis . 
XIV. — ELematemesis . 
XV. — Intestinal Hemorrhage 

XVI. HEMATURIA . 

XVII. HAEMOPTYSIS 

XVIII. — Metrorrhagia — ( Uterine Hemor 
XIX. — Scorbutus — {Scurvy) 
XX. — Anemia— ( Chlorosis) 
XXI. — Hydrops — {Dropsy) 
XXII. — Anasarca 
XXIII. — Ascites 
XXIV. — Hydrothorax 
XXV. — Hydropericardium 
XXVI. — Hydrocephalus 
XXVII.— Scrofula . 
XXVIII. — Bronchocele — ( Goitre) 



rliagt 



PAGB 

512 
514 
516 
518 
520 
523 
524 
526 
528 
530 
534 
537 
540 
543 
547 
548 
552 
555 
557 
561 
566 



CHAPTER XI. 
DISEASES OF THE EYE. 



Section I. — Catarrhal Ophthalmia 
II.-^-Purulent Ophthalmia 
III. — Scrofulous Ophthalmia 
IV.-^Rheumatic Ophthalmia 
V. — Corneitis 
VI.— Iritis 
VII. — Exophthalmia 



568 
571 
574 
576 
578 
580 
583 



CHAPTER XII. 
DISEASES OF THE EAR 



Section I. — General Otitis . 
II. — External Otitis 
III. — Internal Otitis . 



586 
590 
593 



XIV 



CONTENTS. 



Section IV. — Otorrhea 

V. — Otalgia — (Ear-ache) 
VI. — Nervous Deafness 



PAGE 

595 

597 
598 



CHAPTER XIII. 

DISEASES OF THE SKIN 



Section I. — Eashes and Eruptions . 
II. — Red Rash 

III. — Rose Rash — (Roseola) . 
IV. — Nettle Rash 
V. — Papular Eruptions 
VI. — Vesicular Eruptions 
VII. — Pustular Eruptions 
VIII. — Scaly Eruptions 
IX. — Animalcular Eruptions 
. X. — Crtptogamous Eruptions 



601 

605 
606 
608 
609 
611 
614 
617 
620 
621 



CHAPTER XIV. 

DISEASES OF THE URINARY ORGANS. 



Section I. — Nephritis 

II. — Albuminuria . 
III. — Nephralgia 
IV. — Acute Cystitis 
V. — Chronic Cystitis 
VI.— Diabetes Mellitus . 
VII. — Diabetes Insipidus 
VIII. — Lithiasis — ( Gravel) . 
IX. — Suppression of Urine . 
X. — Retention of Urine 
XI. — Dysuria — (Strangury) . 
XII. — Incontinuance of Urine 



626 
630 
634 
635 
637 
638 
641 
643 
650 
652 
653 
654 



CHAPTER XV. 
DISEASES OF THE GENITAL ORGANS. 



Section I. — Spermatorrhoea 
II.— Gonorrhoea . 



656 
663 



CONTENTS. XV 

PAGK 

Section III. — Syphilis ....... 666 

IT. — Metroperitonitis . . . . . 670 

V. — Chronic Metritis ...... 675 

VI. — Disease of the Ceryix Uteri .... 677 

VII. — Leucorrhea ....... 680 

VIII. — Amenorrhea ...... 684 

IX. — Dysmenorrhea ....... 688 

Conclusion ........ 691 

Index .......... 693 



A TREATISE ON THE PRACTICE OF MEDICINE, 



CHAPTER I. 
OF DISEASE 



SECTION I.— NATURE OF DISEASE. 

By disease, is here meant a deviation from health ; and hence by the 
nature of disease, I mean the nature of deviations from the standard of 
health ; in order to understand which, it is proper that we should take a 
glance here at the physical, intellectual and moral constitution of man. 

Man as he came forth from the hand of the Creator was a perfectly 
constituted being; the mind was the essential part, the body being a 
mere instrument of the mind. The mind was probably constituted with 
an intuitive consciousness of self and notion of God ; but to gain a 
knowledge of the material world and for other important purposes, the 
body was an indispensable appendage. As the mind then gained a 
knowledge of the material world through the bodily senses, and by the 
aid of knowledge thus obtained, improved its knowledge of self and 
notions of God, it was a physical, intellectual and moral necessity that 
the body should be a perfect instrument of the mind. 

The necessity of perfect bodies, however, becomes more apparent 
when we remember that if our bodies are imperfect, we fail to acquire 
through the senses, a correct knowledge of the material world ; and as a 
consequence fail to acquire correct knowledge of ourselves, as well as 
notions of God. Thus failing to understand ourselves and the 
material world, as well as to form correct notions of God, we fail to 
appreciate our relations, and hence our obligations to ourselves, to God, 
and to all creatures and things ; thus rendering physical degeneracy, or 
disease of our bodies, not only a physical but an intellectual and moral 
calamity. 

If then our physical, intellectual and moral natures require that we 
have perfect bodies, what principles can be more important than those 
which teach the laws of health and the best method of restoring to 
health our bodies when in a state of disease ? To suppose that man 
was created physically imperfect, or that he must necessarily have become 
so, would be indirectly to charge the Creator with folly and would be in 
the highest degree absurd ; and equally absurd would be the notion that 
anything except man's own imprudence in deviating from the laws of 



18 OF DISEASE. 

health, or of his being, could have led to the present state of physical 
degeneracy. 

It is probable then, if man had always obeyed the laws of his being, 
that we might have escaped pain, disease and death ; and like Enoch 
and Elijah, "having walked with God," we should have been removed to 
a more elevated state or genial clime ; and thus escape the really 
unnatural passage, "through the valley of the shadow of death." 
This appears the more probable when w r e remember that human life 
has been gradually shortened from the first deviation from the laws of 
health to the present time. And whether the first deviation from the 
laws of health, w T hich occurred in Eden, consisted merely in eating the 
unwholesome "forbidden fruit;" or whether it was from moral wrong in 
partaking of that which had been forbidden, or whether, as is probable, 
it was from both ; it matters little, for we are so constituted that every 
deviation from the laws of our being, physical, intellectual or moral is a 
violation of the law T s of health. 

It is unreasonable to suppose that accidents or even the elements in 
nature which now appear to produce disease, would have harmed man if 
he had retained his original purity and always obeyed the law r s of his 
being. 

In fact if we reflect upon the origin of every disease to which we are 
now liable, many of which we inherit, we shall find that they have arisen 
one after another as our multiplied deviations from the laws of health 
have led to them ; every new disease leading the way to or predisposing 
to that which has followed, ns gluttony, drunkenness, licentiousness, 
tobacco, &c, have led to scrofula, and scrofula to consumption. And 
this is equally true of the contagious diseases ; one imprudence after 
another having led to such a degree of physical derangement that a 
particular species of disease is produced, and the system while laboring 
under this particular derangement, generates a contagion which propa- 
gates the disease. Thus it was that licentiousness led to the venereal 
disease ; the system after the disease w T as once produced generating the 
virus or contagion which has propagated the disease. Hence we see 
that instead of the elements being at war with us, it is man that is at 
war with himself and with the elements. And it is by that warfare and 
reckless disregard of the laws of our being that we inherit, and are now 
liable to the vast variety of diseases from which unfortunately we suffer. 

This may be thought foreign to our subject, but I think it is not ; 
especially as we should know whether the ills to w T hich we are liable are 
a necessary result of the order of Providence ; or whether they result 
from our own imprudence and were, therefore, entirely unnecessary. 
Eor if our sickness, pain and death, were a direct result of the warring 
of the elements against our life and health, there would be little left for 
us to do in the matter ; except to fortify ourselves and contend as best 
we could with the order of Providence. But if, as we have seen, all our 
sickness, pain and physical degeneracy is either the direct or indirect 
result of imprudence, we have vast and fearful responsibilities in this 
matter. And the more weighty appear these responsibilities when we 
remember that not only our physical but our intellectual and moral 
natures are implicated in this degeneracy. 



NATURE OF DISEASE. 19 

Now such being the case, in relation to our responsibility in this mat- 
ter, it becomes us, as Christian Medical Philosophers, to see what may 
be done on our part, by way of correction, to lessen the ills to which 
mankind are now liable ; not only by way of prevention ; but also to 
the cure of disease. And if we have arrived at such a state of physical 
degeneracy, that we may never regain our native physical perfection, 
let us do what we can towards reaching that state ; and may we not hope 
that the good time may yet arrive, when "the child shall die an hundred 
years old?" and when disease and pain will be comparatively unknown? 
Until this state of things can be reached, the human family will suffer 
from a variety of ills, which, for the sake of convenience, we will call 
disease. 

Now, we can form no correct notion of disease, till we understand our 
physical organization in health ; and also, the natural functions of all the 
organs and parts of our bodies in a state of perfect health. So that a 
correct knowledge of Anatomy and Physiology, is the only possible 
way for us to acquire a knowledge of deviations from the standard of 
health, or what we call disease. But as Diogenes, more than two thou- 
sand years ago, in wandering with a torch, in open day-light, about the 
streets of Corinth, declared himself unable to find a man; so we at the 
present day, may search in vain for a perfect physical organization, the 
deviations from which to form a correct knowledge of disease. In fact, 
in order to get a perfect standard, we must go back in imagination to 
the infancy of our race ; when the human body, fresh from the hand of 
the Creator, was perfect in all its parts. 

Disease then, is nothing in itself; but consists in a deviation from a 
state of health. Consequently he who does not understand what a heal- 
thy condition should be, can by no possibility arrive at a rational conclu- 
sion in relation to disease. We must take then, the human system, in 
the most perfect state in which we find it at the present day, together 
with our imagination of what it should be, as our standard from which 
to calculate disease ; and we should bear in mind also, that man is a 
triune being ; with mind, body, and a moral nature, and that a healthy 
physical organization is indispensible to the perfect development of the 
intellectual and moral man. 

Anatomy then, and Physiology, is the foundation, not only of Medi- 
cal, but to a certain extent of Intellectual and Moral Philosophy: 
and though we may not be able to comprehend the minute relation be- 
tween the mind and body, we must bear in mind the fact of this rela- 
tion, at every step of our investigation, into the nature, causes, symp- 
toms, diagnosis and treatment of disease. 

if we examine our bodies, we shall find that they are just that kind 
of self-regulating instruments of the mind, which we should suppose an 
All-wise Being would have invented. Or at least they were so, in 
their original state of perfection ; the fluids and solid tissues, being in 
due proportion to each other. The supply of nourishment furnished by 
the food, being exactly sufficient to supply the wastes of the system. 
While then, this balance was preserved, and the fluids and solid tissues 
retained their normal state, as to quality and quantity, the human body 
was in a state of health ; and might have continued so, and probably 



20 or DISEASE. 

retained the health and vigor of youth ; never decaying, never wearing 
out, and thus man, as I have already suggested, might probably have 
remained physically immortal. 

But as we have already seen, we must take the human system as it is ; 
bruised and shattered by the numberless deviations from the laws of 
health, since the creation of man ; every one of which has tended to 
mar this handy-work of God, till we now inherit scarcely constitution 
enough to enable us to live on ; even with prudence on our part to 
seventy years, while those who are imprudent, or inherit a greater de- 
gree of physical degeneracy or imperfection, may scarcely continue even 
a miserable existence through the periods of youth, childhood, or even 
infancy. 

Thus has the human system gone on degenerating, for near six 
thousand years, till few of us inherit constitutions that enable us to live 
past three score years and ten, while the average duration of human life 
is probably less than half that period. 

Now this hereditary physical imperfection, or predisposition to disease 
or premature death or decay, differs in different individuals, some inherit- 
ing it as we have seen, in a greater and others in a less degree, and 
some tending to dissolution in one way, and others in another. And 
while, as we have already seen, we have to take mainly the system in 
health, as it is at the present time, as the standard from which to calcu- 
late disease ; we cannot proceed a single step, in our inquiry into the 
nature, causes, symptoms, diagnosis and treatment of disease, without 
understanding, and taking into account the inherited imperfection of 
constitution, or predisposition to disease, in each particular case. 

In relation to the nature of hereditary or inherited physical imperfec- 
tion, or predisposition to disease ; we have already seen, that it varies 
materially in different individuals, not only in degree, but in kind ; some 
tending to an early death in one way, and others in another. But it is 
probable that in every case, the leading or prevailing physical imperfec- 
tion of both parents are entailed upon the offspring, rendering the whole 
physical organization, including fluids and solids, more or less imperfect; 
but the leading imperfection in the constitution of the child, being similar 
to that of one or both parents ; from which, it should be remembered, 
every particle of the material, fluid and solid, of which the new-born in- 
fant is composed, has been derived. 

Hence it is, no doubt, that children are born scrofulous, tuberculous, 
syphilitic, &c. ; literally fulfilling the declaration of the Almighty, that 
" the iniquities of the fathers," shall be "visited upon the children;" 
and that too by a necessary law of nature, which is really however little 
more than another term, to indicate a decree of the Almighty. 

Having thus inquired into the nature of hereditary imperfection or 
disease, or predisposition to disease ; we are now prepared, keeping the 
facts here arrived at in mind, to arrive at rational conclusions, in our 
examination into the nature of acquired disease, which now demands 
our consideration. 

A person may be said to be in health, when the fluids and solid tissues 
of the body are in such a state, that all the functions of the body are 
carried on harmoniously ; taking into account of course, hereditary 



NATURE OF DISEASE. 21 

physical imperfection, or predisposition to disease. But all variations 
from this standard, involving a derangement of structure or function, 
and causing suffering, or endangering life, we may call disease. 

For the sake of convenience, disease involving a change of the com- 
position of the fluids, or structure of the solid tissues may be called 
organic ; while those derangements in the functions of the body, not in- 
volving any apparent change in the composition of the fluids, or struc- 
ture of the solids, may be called functional. It is possible that all dis- 
eases may involve a change in the composition of the fluids, or structure 
of the solids ; but in all cases in which the organic change is not percep- 
tible, the derangement may be regarded as functional. 

Disease again, may be either general or local ; in the one case, involv- 
ing more or less, every organ and tissue of the body ; while in the other, 
it is confined more especially, to some particular organ or tissue. 

The fevers, and general inflammatory affections, may be called gene- 
ral, while those diseases of whatever character, which involve only par- 
ticular parts, organs, or tissues, as the brain, lungs, liver, skin, &c, 
properly fall under the head of local disease ; though attended usually, 
with more or less general disturbance. 

Now to understand the nature of general disease, it is necessary to 
bear in mind the composition of the blood, and other fluids of the body, 
as well as the structure of the different tissues, and the relation existing 
between the solids and fluids. When this is done, it will be impossible 
for us to refer any general disease, exclusively to either the blood or 
solid tissues. For though the cause, whatever it may chance to be, may 
operate primarily upon the blood ; its influence is immediately felt upon 
the brain and nervous system. And as the character of the blood, as 
well as condition of the solids, depend upon a due amount of nervous 
influence ; we soon have a general derangement of the fluids and solids, 
of either an organic or functional character. 

On the other hand, if the cause acts primarily upon the solids ; as for 
instance, a fright acting through the mind upon the brain and nervous 
system, the blood becomes instantly involved, in consequence of the 
derangement which occurs in the generation and distribution of the ner- 
vous influence, affecting the circulation and also the secretions generally. 
Again, when we remember that the formation of the blood depends upon 
the condition of the solid tissues of the digestive apparatus, as well as 
of the nervous system, and that the integrity of all the solid tissues de- 
pend upon a constant and due supply from the blood ; we see at once 
the utter impossibility of referring any general or even local disease, 
exclusively to either the fluids or solids. 

In all general or local diseases then, whether organic or functional, 
the derangement involves more or less the blood and solid tissues, which- 
ever may have been the medium, through which the morbid agent or 
influence has primarily operated. 

Now, we may have general or local disease from every possible devia- 
tion from the laws of health, and rules of propriety, as well as from 
hereditary and other influences, in a certain degree beyond our control, 
at the present day ; some of which act upon, and change more or less 
the quality, quantity and character of the blood, directly ; while others 



22 OF DISEASE. 

act directly upon the solid tissues, as moral influences, impairing the 
vitality of the cerebro-nervous system, hindering a due generation and 
proper distribution of the vital force, or nervous influence; and thus 
producing disease : causes then operating in either of these ways, may 
lead to irritation, congestion and inflammation, to the febrile, and gene- 
ral inflammatory affections ; and also, to functional or organic diseases 
of the nervous, digestive, respiratory and circulatory systems, or their 
structures, as well as to diseases of the eye, ear, skin, urinary and genital 
organs. 

Now, when we bear in mind, that the human system is composed of 
the fluids; and the solid tissues, consisting of the cellular, muscular, 
nervous, &c, so combined as to form the structures of the different or- 
gans of the body; and remember that all the organs depend upon a due 
amount and proper distribution of the nervous influence, for the perfor- 
mance of their functions ; we can scarcely overrate the influence which 
the brain and nervous system has, in all diseases of an organic or functi- 
onal character; and local as well as general. It must however be borne 
in mind, at every step, that the brain and nervous system depend upon 
a due amount of stimulus from the blood, to enable them to generate 
and distribute sufficient nervous influence to enable the organs of the 
body to carry on their functions. 

We may conclude then, that disease consists in a derangement of the 
system, either general or local, involving more or less the fluids and 
solid tissues of the body, and especially the blood and nervous system, 
and embracing every possible deviation, whether organic or functional, 
from the standard of health. 

Having now completed what I have to say here on the nature of dis- 
ease; I shall leave this subject and in the succeeding sections of this 
chapter shall consider the causes, symptoms, diagnosis and treatment of 
disease. In the following chapter I shall consider irritation, congestion 
and inflammation; in the third, the pathology, causes and phenomena of 
fever; in the fourth, general fevers ; in the fifth, exanthematous fevers, 
and the sixth, the general inflammatory diseases. 

Having thus considered the more general diseases to which the human 
system is liable ; I shall proceed to take up the diseases involving more 
especially particular parts, in the following order : 

In the seventh chapter, diseases of the nervous system; in the eighth, 
diseases of the digestive system ; in the ninth, diseases of the respiratory 
system ; in the tenth, diseases of the circulatory system ; in the eleventh, 
diseases of the eye ; in the twelfth, diseases of the ear ; in the thirteenth, 
diseases of the skin; in the fourteenth, diseases of the urinary organs ; 
and in the fifteenth, diseases of the genital organs ; ending with a short 
conclusion, which will complete this Treatise on the Practice of 
Medicine. 

SECTION II.— CAUSES OF DISEASE. 

By causes of disease ; technically etiology ; Jjmean here any and every 
agent or influence capable of deranging, either directly or indirectly, any 
function or structure of the body. It includes of course, along with 



CAUSES OF DISEASE. 16 

hereditary imperfection, every imprudence to which the human family 
are addicted, which always predispose to, and often excite disease : and 
also all those agents in nature, which, in consequence mainly of this pre- 
disposition, are exciting causes of disease. 

Now it is evident that every cause which is capable of predisposing 
the system to disease, is capable, under other circumstances, of acting as 
an exciting cause of disease ; and also that the exciting causes, under 
circumstances which favor it, predispose the system to disease. With 
this qualification, I prefer to consider the causes of disease as predispos- 
ing and exciting ; and will, therefore, proceed first to consider the more 
important abuses of the body, and imprudences which always predispose 
to, and often excite disease ; under the head of predisposing causes ; and 
tfcen will take up those agents or influences in nature, which more gene- 
rally act as exciting causes, under the head of exciting causes of disease. 

It is highly proper, however, in order to appreciate all the direct and 
indirect causes of disease ; that we bear in mind continually the anatomy, 
physiolog} r and functions of the body in health : and also salutary influ- 
ences ; such as cleanliness, proper food and drink, clothing, temperance, 
virtue, contentment, $c, which tend to perpetuate health ; that we may 
the more readily appreciate the imprudences and influences, which have a 
pernicious effect, and produce disease. 

PREDISPOSING CAUSES OF DISEASE. 

By predisposing causes of disease, I mean here all those disturbing 
influences which operate upon the human 'systenTto weaken the powers 
of vital resistance, and thus render the system susceptible of being thrown 
into a state of disease, by various elements, and influences in nature, 
which except for this predisposition, might, in most cases at least have 
remained harmless. 

It will not be expected, of course, that I shall enumerate all the pre- 
disposing causes of disease ; but I will endeavor to consider those impru- 
dences and abuses of the body, which are of practical importance, and 
which I am confident, from careful observation in numerous cases for 
nearly twenty years, not only predispose the system to acute disease ; 
but also lay the foundation of physical, intellectual and moral weakness; 
as well as for permature decay and death. And as most of these 
causes are avoidable ; and as many of them would be avoided by thou- 
sands in the community, if they were sufficiently enlightened, I cannot 
exaggerate the importance of this subject ; and would urge it upon my 
brethren of the Medical Profession, as Christian Philosophers, and as 
benefactors of mankind. 

Hereditary Predisposition. — Hereditary predisposition or tendency 
to disease, consist in whatever defect or imperfection we may be born 
with ; the result of every departure from the laws of health of our an- 
cestors, even back to the first pair in "Eden." And, also, we may in- 
clude those accidental influences in nature, which have had a pernicious 
effect, in consequence mainly, of acquired predispositions. 

I need not say that the vices of every preceding age, have had their 
influence in lessening the powers of vital resistance ; in shortening 
human life, and in rendering the human system, even in new-born 



21 OF DISEASE. 

infants, immeasurably below its original standard of perfection. Hence 
it is, no doubt, that human life has an average now of less than forty 
years ; while our early ancestors, who did not inherit the result of impru- 
dences practised by more than one or two generations, lived in some 
cases, near one thousand years. 

Now while ten thousand influences must have been operating for 
nearly six thousand years, to bring about this state of hereditary physi- 
cal imperfection, or predisposition to disease ; I think it must be admitted 
that filth, improper clothing, improper and insufficient food, intoxicating 
liquors, licentiousness in its various forms, the violent angry passions, 
and latterly tobacco, have contributed largely, and probably mainly, to 
bring about this hereditary tendency to disease ; for Avhich the individu- 
als composing this generation are in no way responsible. It is probable 
also, that the marriage of near relatives, since hereditary imperfections 
have prevailed, has also had a very pernicious influence, in cases in which 
it has been practised. 

Now such being the origin, and some of the causes of hereditary 
tendency to disease ; we should expect, as we really find ; that this pre- 
disposition would vary materially in different individuals, families, and 
races of men ; depending much upon the customs, habits, and impruden- 
ces of their progenitors. And thus it is, no doubt, that we find some 
individuals, families and races of men, predisposed to one form of disease, 
and others to another. 

But this reflection upon the past is important, only as it points out 
indication to us for the present and future ; a matter for which we are all 
more or less responsible, and in which we should be deeply interested. 
This in fact appears the more important, when we remember that the 
same chain of pernicious influences, with a corresponding shortening of 
human life, that has attended them thus far, would in less than five 
hundred years more, exterminate the human family.* 

Hereditary predisposition to disease is a matter, then, never to be 
overlooked ; and while we cannot hinder that which is past, let us in all 
our intercourse with our fellow-men strive to inculcate those principles 
of righteousness, which may show a diminution of this predisposition in 
succeeding generations. 

Filth. — Filth, or want of cleanliness, is another predisposing cause 
of disease. This, it is true, is a cause which does not, directly, very 
extensively prevail in civilized communities ; but indirectly it affects all 
classes : for we have only to remember that a very small den of filth 
may become a pest, by the impurity which it imparts to the air, which 
may operate perhaps insidiously upon the most cleanlv, who would them- 
selves gladly obey the laws of health and life. 

Filth operates directly upon the systems of those addicted to the dis- 
gusting habit, by hindering a due exhalation from the skin ; in conse- 
quence of which the various functions of body are rendered exceedingly 
liable to become deranged, by very slight exciting causes. This may be 
noticed in all cases in which there is an endemic or epidemic influence 

* Men lived about 1000 years, near 5000 years ago ; now the average of hiiman life is 
less than 40 years ; hence human life would be reduced, at the same rate, below the age 
for generation, in less than 500 years more. 



CAUSES OF DISEASE. 25 

operating upon a community ; the filthy, as a general rule, being by far 
the most frequent victims of the influence of the general exciting cause. 
Strict personal cleanliness, then, should always be enjoined; not only to 
lessen the predisposition to disease among those addicted to it, but also 
as a security for those who maintain strict cleanliness themselves, and 
would gladly obey the laws of health and life. 

Food. — Food becomes a predisposing cause of disease, if it be im- 
proper, too much, too little, or if it be taken irregularly ; all of which 
deviations from that which is proper require our careful consideration. 

Improper food may be so from its indigestible properties ; in which 
case it not only fails to afford the system the nourishment it requires, 
but it also acts as an irritant to the alimentary mucous membrane, caus- 
ing irritation, inflammation, &c, and leading or predisposing to dyspepsia, 
chronic diarrhoea, and a long train of gastric, hepatic and other diseases 
too numerous to mention. Or food may be digestible, and yet be highly 
pernicious, from the fact of its being of an unwholesome character, and 
wanting the nutritive properties ; as, for instance, putrid meats. In 
such cases, the system not only fails to receive its required nourishment — 
which of course lessens the powers of vital resistance — but the putrid or 
unwholesome material which it furnishes the system depraves or decom- 
poses the blood ; thus rendering the system tenfold more liable to attacks 
of acute disease from slight exciting causes. 

Too much food, by hindering the digestive process, and also irritating 
the gastro-intestinal mucous membrane, predisposes to disease of the 
digestive system ; or if digested, it may convey too much of the stimu- 
lating properties into the blood, and thus strongly predispose the system 
to various acute inflammatory affections, from comparatively slight ex- 
citing causes. 

Insufficient amount of food, by cutting off the necessary supplies for 
the blood, soon renders the nervous system irritable, and lessening the 
powers of vital resistance, strongly predisposes the system to attacks, 
from slight accidental causes, of neuralgic, congestive, or passive inflam- 
matory diseases. 

Irregularity in taking food is, according to my observation, one of 
the most prevalent and fe arful predisposing causes of disease. The 
stomach will receive and digest a reasonable amount of food, taken at 
regular intervals — three or four times in twenty-four hours — and in that 
case, if the system is in an ordinary state of health, the stomach will 
call for about the amount of food it can well digest, or that the system 
requires. 

If, however, food be taken at irregular hours, or between meals, as is 
too generally the case, especially with children, the stomach, for want of 
rest, becomes unable to properly digest the food taken ; the gastro- 
intestinal mucous membrane becomes irritable ; acids are generated in 
the stomach to excess : the appetite becomes irregular ; too much or too 
little food is taken ; a due supply of nutriment for the blood is cut off; 
the nervous system becomes irritable ; all the fluids and solid structures 
of the body become more or less deranged, and the patient becomes 
strongly predisposed to scrofula, consumption, dropsy, epilepsy, cata- 
lepsy, and, in fact, almost every variety of disease to which the human 



26 OF DISEASE. 

system is liable. If now to the sum of physical wretchedness which the 
habit of irregular eating produces, we add the inconvenience which 
attends it, and then take into account the fact that there is no excuse 
for it, the prevalence of the habit is one of the most wonderful and 
alarming of the age ; and, without doubt, is one of the most frequent 
exciting, as well as predisposing, causes of disease. 

Clothing. — Improper clothing, by affording the system insufficient 
protection from winds, moisture and cold, predisposes the system to 
various acute inflammatory affections. If the amount of clothing be too 
much, the system by degrees loses its capacity of adjusting its tempera- 
ture to atmospheric changes ; and hence, if from inattention to the mat- 
ter, as the temperature of the air falls suddenly, the clothing be not 
correspondingly changed, there is a strong liability at least that some 
inflammatory or catarrhal affection may be the result. If, on the other 
hand, the clothing is defective, or insufficient to protect the system, the 
cutaneous exhalation is liable to be greatly diminished, and the per- 
spirable matter being retained in the blood, predisposes the system to 
various functional and even organic affections. 

Licentiousness. — Licentiousness, whether it be from masturbation, 
as too often practised by the young and unmarried, or from Onanism, 
or from excesses in sexual intercourse, as too often practised by the mar- 
ried, and by the grossly licentious unmarried, is an alarming predis- 
posing cause of disease. 

Masturbation, as thousands of degraded objects of pity clearly demon- 
strate, impoverishes the blood, irritates the genital organs in both sexes, 
exhausts the nervous energy, debilitates the brain and whole nervous 
system, produces general physical, intellectual and moral weakness, or 
depravity, and strongly predisposes the unfortunate sufferer to melan- 
cholia, hypochondria and insanity ; as well as to a vast train of func- 
tional and organic diseases. 

Onanism* by interrupting the free discharge of the seminal fluid 
from the male organ, generally sooner or later produces an irritation of 
the seminal ducts, of the vesiculas seminales, and also, in many cases, 
of the prostate gland ; and being only a species of masturbation, and in 
every respect at variance with the order of nature, affects the genital 
organs of both sexes, and, in fact, the whole organization of the system, 
in a manner very similar to that already described as the result of mas- 
turbation, and thus of course becomes an alarming predisposing cause of 
disease. 

Excessive sexual indulgence, though less injurious than masturbation, 
as practiced by the unmarried, or than that form of masturbation termed 
Onanism, practised by the married and by the grossly licentious, is in 
too many cases a dangerous draft upon the blood and nervous energy ; 
and thus, no doubt, is very often a predisposing cause of disease. And 
irritating as it does the female genital organs, it soon affects the nervous 
system, and becomes scarcely a less evil to the female than to the male 
thus practicing. 

Thus we see that licentiousness, in all its forms, is a fearful predispos- 
ing cause of disease. 

* See the practice of Onan, in the Bible, Genesis xxxviii. chapter and 9th verse. 



CAUSES OF DISEASE. 27 

Intoxicating Liquors. — Intoxicating drinks, whether taken in the 
form of fermented or distilled liquors, are a very frequent predisposing 
cause of disease. If taken in small quantity, and at regular intervals, 
as for instance after each meal, they are very liable, sooner or later, to 
irritate the mucous membrane of the stomach ; and being long continued, 
the nervous system becomes debilitated to such an extent, that the sys- 
tem is scarcely able to carry on its functions without it. If now the 
liquor be continued, in order to keep the system up, it has to be increased 
in quantity. This gradually increases the gastric irritation, and nervous 
debility, till the system becomes so far reduced, that a suspension of the 
liquor from any cause often leaves the patient in a state of delirium, 
literally, " madness from the bowl." Thus we see, that the use of intoxi- 
cating liquors leads to delirium tremens, and it is notoriously true, that 
protracted drunkenness leads to a great variety of physical disease, as 
well as to intellectual weakness, and moral depravity. 

Tobacco. — Tobacco, containing as it does three deadly poisonous prin- 
ciples : Nicotia, Nicotianin and an Empyreumatic oil, is a fearful cause of 
disease, especially as it is so generally used by smoking, snuffing and 
chewing ; the poisonous principles entering the circulation, and directly 
impairing vitality, by disqualifying the brain for generating sufficient vital 
force or nervous influence ; and also disqualifying the nerves for a proper 
distribution of that which is generated. In this way, it produces nervous 
tremors, and strongly predisposes to paralysis of the lower limbs, as well 
as to a host of functional, organic and mental, diseases. 

Angek. — Anger, especially if it be of a violent character or grade ; 
or if it be indulged for a protracted period, is sure to produce a functional, 
if not an organic disturbance in the system ; and predisposes not only to 
a variety of physical diseases ; but also fearfully endangers, the intellect- 
ual and moral powers. 

Now having enumerated the prominent predisposing causes of disease, 
and having given a brief explanation of the manner in which these causes 
thus act to predispose to disease. I want it distinctly understood, that 
they may all, under other circumstances, or if long continued, become 
exciting causes of the diseases to which we have seen they predispose. 
Bearing these facts in mind, we are prepared to pass on to the consider- 
ation of those elements or influences in nature, which more generally 
act as exciting causes of disease. 

EXCITING CAUSES OF DISEASE. 

Heat. — A moderate degree of heat is essential to vegetable as well as 
to animal life ; and it only requires the exercise of a sound discretion, for 
every individual to guard himself against its pernicious influences. 
"Without the exercise of this discretion however, heat may become a 
frightful exciting cause of disease. This we see illustrated in " sun 
stroke,'" caused by an undue exposure to the piercing rays of the sun, in 
persons especially predisposed to the affection. 

Again, we see it illustrated in its direct affects when applied to the 
human body in water, steam, or as is latterly more frequent, in the rapid 
combustion of various inflammable fluids, so generally, and as I believe 
improperly used for lights ; a fearful case of which fell under my care, a 



28 OF DISEASE. 

few weeks since in this village. Thus we see that heat, an essential life 
giving principle or agent, becomes through carelessness and imprudence, 
and the failure to exercise a sound discretion, a fearful exciting cause of 
disease. 

Cold. — Cold is a negative condition, and implies an absence of caloric 
or heat ; hence we may see at a glance, that a due degree of cold is indis- 
pensable, for all living beings and things. And a judicious exposure to 
it, by human beings is always salutary, and always a source of comfort. 
It is only then from an undue exposure to cold, and that too more gene- 
rally by persons weakened by previous improper exposures to heat, or 
other influences, that cold becomes an exciting cause of disease. 

By the improper sudden exposure of the body to cold, after it has been 
overheated, an interruption of the perspiratory function is liable to follow, 
attended with some acute inflammatory affection, thus rendering cold, 
injudiciously applied, an exciting cause of disease. Again, cold may be 
improperly applied to the system for a long time, or the body may thus 
be exposed to its influence, till its sedative or depressing effects may so 
far interrupt the various functions of the body that scrofula, dropsy, con- 
sumption, &c, may be the result, as we see illustrated in many of the men 
who accompanied the late illustrious Dr. Kane, in his northern expedi- 
tion in search of Sir John Franklin. 

One of these noble men, whose constitution suffered, but did not give 
out during that long voyage, fell under my care a few months since. 

Finally, cold may, by its intensity, and its prolonged application, pro- 
duce a depression which will interrupt the circulation, depress the mus- 
cular power, benumb the brain and whole nervous system, and finally, 
interrupting one function after another, it leads to an irresistible drowsi- 
ness, which is followed by death. Thus we see that cold, while it is 
essential to life and health, in a due degree, becomes, if the body be 
imprudently exposed to its influence, an exciting cause of disease ; and 
may even produce fatal effects. 

Water. — Water again is an element indispensable to the very existence 
of all living beings ; and for the comfort and well-being of man, it is indis- 
pensable as a drink, and convenient at least, for ablution ; and yet strange 
as it may seem, its improper use, in various ways aticT forms, renders it 
a frequent exciting cause of disease. Too much water taken into the 
stomach when the body has been overheated, especially if it be cold, is 
liable to produce alarming effects. Or the habit of taking too much 
water at meals, or at other times, is liable to dilute the gastric juice to 
such a degree, as to render it incompetent to dissolve the food ; and hence 
dyspepsia, with all its consequences is the result. I had an alarming 
illustration of this, in a little boy of this village, a few weeks since, which 
was cured only after I prohibited his drinking large draughts of water, 
frequently during the day and night. 

Again, water may be drank too hot or too cold ; and in either case, is 
liable to produce the most "fearful results. Or by being applied too hot 
or too cold, or too frequently "to the surface of the body, it is liable to 
produce too great stimulating or depressing effects, and thus to disturb 
the distribution of the nervous influence ; or at least, to call the skin into 
undue activity ; causing it to throw off offensive waste matters from the 



CAUSES OF DISEASE. 29 

system, which should pass by the kidneys or through the alimentary 
canal, thus rendering the skin more filthy, than if only washed with 
water of a medium temperature ; and at proper intervals. Thus we see 
that water, which is indispensable to the life and comfort of man, is liable 
when improperly used or applied, to become an exciting cause of disease. 

Electricity. — Electricity is a principle which pervades the human 
body as well as almost every object or substance in nature ; and might 
very likely have been a universal source of health and comfort, if our 
systems had retained their original state of perfection, and provided a 
due amount of caution and prudence were always exercised in avoiding 
it in too violent a shock. 

It is a well known fact that damp air is always in a low electrical 
state ; and that very dry air is highly charged with electricity. Now 
through carelessness or inattention if the air of an apartment becomes 
excessively dry, the electricity with which it becomes charged may 
produce too stimulating effects upon the nervous system ; and thus it 
may become an exciting cause of various acute inflammatory diseases. 
On the other hand, if people expose themselves in low places or apart- 
ments where the air is damp, and of course in a low electrical state, the 
system imparts its electricity to the surrounding air to produce an 
equilibrium ; and thus a portion of the necessary stimulus for the 
nervous system being removed, if it be continued for a long time is very 
liable to derange the various functions of the body, and thus it may 
lead to dropsical, scrofulous and tuberculous diseases. 

In relation to the effects of violent shocks of electricity, as it reaches 
us from the clouds, a sound discretion should always be exercised as in 
every other means of self protection, and with the knowledge we have 
of the protection afforded by conductors placed where persons or 
buildings are exposed ; its fearful effects from such a source and in such 
a form may generally be averted. 

Light. — Light is another agent in nature of inestimable value ; 
originating by the will of the Almighty in " the morning of creation," 
it has opened to the mind, through the organ of sight, the handy- 
works of God by which we are everywhere surrounded. This agent 
probably favors a healthy action in the animal functions, as it is well 
known to in vegetable life. Light is the proper stimulant for the eye, 
and only becomes an irritant when admitted in undue brilliancy, or when 
acting upon the organ previously debilitated or irritated from some other 
cause. 

Aerial Poisons. — Various gasses, as carbonic acid, carbonic oxide, 
carburetted hydrogen, &c, are liable to be present in the air in certain 
localities, and a little caution may be necessary in avoiding them. 

Carbonic Acid, it is well known, is one of the products of respiration 
and combustion, and is the gas from which vegetables and trees obtain 
their carbon or charcoal ; they absorbing this gas through their leaves 
retaining the carbon and throwing off the oxygen in a pure state to 
support animal life. Now the proper constituents of atmospheric air. is 
one part of oxygen to four parts of nitrogen, by volume. If then 
carbonic acid or the other noxious gasses be mingled with it to any 
considerable extent, it is liable to produce disease either by want of a 



80 OF DISEASE. 

due amount of oxygen in the air respired to support the vital flame, or 
the gas may produce a positive injurious effect and thus cause disease. 

As carbonic acid is the~most practically important of these gases, it 
is proper that we should remember that its action in a diluted state is 
probably by hindering the due escape of the same gas from the lungs, 
■where, it will be remembered, it is being formed by a union of the oxy- 
gen of the air with the carbon of the blood. As a consequence of this, 
carbonic acid accumulates in the blood, and, passing to the brain, pro- 
duces its narcotic effect, with stupor, and, if long continued, may cause. 
a suspension of the voluntary and vital functions, from the cerebral 
oppression. 

It is probable, however, that carbonic acid, in a pure or concentrated 
state, causes death by producing a spasm of the glottis, leading to com- 
plete asphyxia. 

Now, as carbonic acid is heavier than common air, it may generally 
be avoided, at least in the concentrated form in which it is likely to pro- 
duce disease. 

In wells, cisterns, deep pits, &c. in which it is liable to accumulate in 
a dangerous degree of concentration, it is always proper to let down a 
lighted candle before the laborers are admitted, and if it be found that 
there is sufficient oxygen to support combustion, there will be enough to 
support the vital flame. 

Vegetable Poisons. — Vegetable poisons exist in various degrees of 
concentration ; all of which, if taken into the system in undue quantity, 
are liable to produce disease, and some of them even death. It is not 
necessary, however, for me to enumerate them here, as the good sense with 
which God has endowed His creatures, generally enables them to avoid 
their pernicious influences — if we except one, and that the most dis- 
gusting of them all, " Tobacco." 

Mineral Poisons. — Various mineral poisons may excite disease, such 
as lead, arsenic, copper, &c. ; but here again a sound discretion may gene- 
rally avoid their noxious effects. I need not say that all the poisonous 
minerals, and especially lead, arsenic and copper, should be avoided as 
conductors for water, or as culinary or household dishes or utensils. 
And I believe further, that lead, even as a paint, should be avoided as 
far as possible. I am compelled to this conclusion in relation to the 
above-named and other poisonous minerals, from a careful observation 
of the fearful diseases of which, I am confident, they are so frequent 
exciting causes. 

Parasites. — Various animal and vegetable parasites are liable to 
cover or infest the human body. But a minute account of them here 
would be of no practical value. One important fact in relation to them, 
should, however, be borne in mind, and it is this : if these parasites are 
to be regarded as causes of disease, whether vegetable or animal, their 
presence in or upon the human body is always attributable to a predis- 
position produced by some previous imprudence ; and generally, as I 
believe, to previous filthy habits. This position appears the more cer- 
tain, when we remember that vegetables thrive but poorly, or will not 
even grow at all, where there is no soil to nourish them ; and that ani- 
mals will not thrive, or even live at all, where their right of possession 
is stoutly disputed, by a " stronger than they." 



CAUSES OF DISEASE. 31 

KoiNO-MlASMATA or Malaria. — Koino -miasmata, malaria, or, in 
other words, the paludal poison, is no doubt a powerful exciting cause 
of disease. This agent, whether it consists of sulphuretted hydrogen, 
animalcules, microscopic fungi, or of some unknown principle or com- 
pound, is freely generated wherever water, with decomposing vegetable 
matter, is exposed to a temperature of from 60° to 80° Fahrenheit. 
The paludal poison is generated more copiously as the marshes dry up ; 
the vegetable decomposition probably going on most rapidly at such 
times ; the miasmata or malaria being also carried into the air with the 
ascending vapor, for which they appear to have a strong affinity. This 
fact we have seen illustrated in the beautiful and usually healthy village 
of Geneva, at the foot of Seneca Lake, in the State of New York. Five 
years ago the rains filled our lake so that it overflowed the lowlands at 
its foot, a little to the east of the village. This appeared to produce 
little disease with us the first season, but the two succeeding years, as 
the water settled in the lake, leaving the overflowed lands, consisting 
mainly of vegetable matter, to dry up, ague, bilious remittent fever, 
bilious diarrhoea, &c, were very prevalent in and about the locality. 
Now, as the outlet of the lake has been dredged, and a large ditch cut 
through the lowlands, and as the soil of these lands has become dry, the 
miasmatic diseases have mostly disappeared. 

It is probable that miasmata are taken into the air, in connection with 
moisture, for which, as I have already intimated, they evidently have a 
strong affinity, and being considerably heavier than common air, they 
are carried along by winds, or gentle breezes, near the surface of the 
ground, being interrupted often by a forest, buildings, or even high 
fences, till gradually their interception by various objects, and their 
dilution with pure air, render their influence comparatively harmless. 
Thus it is, in my opinion, that koino-miasmata seldom penetrate far into 
a large city, or extend their influence far from their source in a wood- 
land region. 

The paludal poison appears to have the power to support vegetation, 
and hence it is in part, no doubt, that miasmatic diseases are less fre- 
quent in the early summer, when vegetables are in full growth, than in 
autumn, when vegetation no longer appropriates it. 

Now, of whatever koino-misasmata, malaria, or the paludal poison 
may consist, it probably enters the blood through the lungs, stomach, 
and perhaps the cutaneous absorbents, and thus becomes a fearful ex- 
citing cause of disease. Of the manner in which it operates, theTSiseases 
w r hich it produces, the distances which it may be carried in the air to 
produce them, the best means of avoiding its pernicious influence, &c, I 
shall take up more fully when we come to consider the causes of fever, 
in a succeeding chapter. It may be proper, however, as of general ap- 
plication, to state here, that localities in which marsh miasmata are 
general, should be improved by ditching, cultivation, &c. ; and further, 
that persons necessarily building in such localities, should seek out the 
most elevated site possible ; and that persons living in such localities 
should keep in-doors at evening and early morning ; and, finally, that 
they should sleep as high from the ground as possible, thus to avoid as 
far as may be this unpleasant miasmatic agent. 



32 OF DISEASE. 

Before leaving this subject however, it may be proper to raise the 
question ; how far, if at all, koino-miasmata would have been injurious to 
the human system ; provided the laws of health had always been observed, 
and our constitutions had never been depraved. There may be room 
here for an honest difference of opinion. But as the system gradually 
becomes accustomed to its influence, and, as it is said, even requires it, 
after long years of exposure to it, I incline to the opinion, that if the 
human system had not been contaminated and debilitated by other un- 
necessary influences, that it would either have remained harmless to us, 
or else we should have retained good sense enough to have kept beyond 
its reach. 

Idio-miasmata or Animal Effluvia. — By Idio-miasmata, or animal 
affiuvia or poison, I mean here the noxious effluvia which result from the 
decomposition of exhalations and excretions from the bodies of persons of 
filthy habits, when crowded together in jilthy confined apartments, &c, 
but do not include under this head, those emanations which are the result 
of a secretory process ; and which have the power of producing the same 
disease in others, by which they have been produced, namely the conta- 
gions. 

Idio-miasmata or the animal effluvia, are generally exhalations from 
the feces, and also from decomposed urine, perspirable matter, saliva, &c, 
in filthy, confined apartments, where these matters are allowed to ^accu- 
mulate. These effluvia may accumulate at any time, and in any place, 
where the matters from which they exhale, are allowed to accumulate 
in quantities sufficient. It is generally, however, in cold seasons of tFe^ 
year, when filthy apartments are kept most closed, that these effluvia 
accumulate in sufficient degree of contraction to produce disease. It is 
doubtless in the main owing to this, that the low typhous fevers, or dis- 
eases which they produce, more generally prevail in cold seasons of the 
year. 

The exact nature or composition of idio-miasmata or the animal efflu- 
via, is not definitely known ; but it appears highly probable, that sulphur- 
etted hydrogen, is at least a constituent part. It is quite certain however, 
that they enter the blood, through the lungs, stomach, and probably the 
skin ; and that while they directly depress the nervous system, they also 
partially decompose or corrupt the blood, and thus become an exciting 
cause of disease. 

In relation to these effluvia, it is hardly necessary to say, that the cir- 
cumstances, which lead to their exhalation, should always be avoided, 
and this I believe may generally be done, by a rigid enforcement, of 
proper sanitary regulations. 1 believe in this respect, that an improve- 
ment might be made in our sanitary laws, by a careful reference to those 
sanitary regulations which God gave to Moses and Aaron, for the Israel- 
ites ; and which were rigidly enforced, during their journeyings in the 
wilderness.* 

Contagion. — By contagion, Xjiiean here any product of a peculiar 
disease, whether in a solid, fluid or "aeriform state, which is capable of 
producing the same disease in another person ; and of propagating 
itself as well as the disease of which it is the cause and effect, " through 

* See Leviticus XVth, and other Chapters of Leviticus in the Bible. 



CAUSES OF DISEASE. 33 

any number of unprotected individuals," the disease thus propagated 
being properly called contagious. 

Contagion may be the product of secretion or exhalation ; and it 
acts in a solid or liquid form, either by simple contact as in gonorrhoea 
and syphilis, or else by application to an abraded surface or wound as in 
vaccination and hydrophobia ; while in the aeriform state, through the 
atmosphere, it probably acts mainly by inhalation through the lungs. 
It should further be remembered that contagious matter may be the 
result of local action in a diseased individual, as in syphilis, &c, or it 
may be exhaled from the whole surface of the body, as in typhus, 
scarlatina, measles, kc. 

Contagion in the aeriform state may not be conveyed to any very 
considerable distance by the air in a degree of concentration sufficient 
to produce its disease, but it is quite certain that the effluvia, as well as 
the solid and liquid forms, may become attached to cloths, and especially 
to filthy articles, and thus be conveyed to great distances ; thus retaining 
also the power of communicating its disease for a considerable time. 

The period of incubation in contagious diseases varies from two or 
three days to several weeks; and the diseases are generally attended 
with febrile action, very generally run a tolerably definite course, and in 
many of them the system becomes insusceptible to a second attack. 
Thus we see that the contagions become a frequent exciting cause of 
disease, subjecting almost every individual born into the world, at the 
present day, to a train of diseases ; through which if he pass unscathed 
he may do well. This naturally leads us to inquire into the origin of 
contagious diseases ; and to see, as Christian philosophers, whether they 
might have been or may yet be avoided. 

Now it is absurd to suppose that God made these contagions, as for 
instance that of syphilis, and then created a predisposition in the system 
to them ; thus directly forcing them upon us without fault on our part. 
We must then take the other horn of the dilemma and conclude, as every 
circumstance appears to imply, that imprudence in deviating from the 
laws of health has created not only the predisposition, but has also 
caused each of the contagious diseases to originate one after another till 
we have arrived at the present catalogue. If then this be so, wider 
deviations from the laws of health, longer continued, will swell the 
catalogue. On the other hand, better sanitary regulations, better 
morals, and a more rigid observance of the laws of health, by the 
community in general, might greatly diminish the number of contagious 
diseases and perhaps in the end might exterminate them. 

This theory in relation to the origin of contagious diseases, appears 
the more probable, when we remember that most, if not all, the 
contagious diseases, even now very frequently arise without an exposure 
of the person to the contagion generated in another patient, the result 
no doubt in such cases of various imprudences ; the system once in the 
diseased state generating a contagion which propagates the disease. 

Endemic Influences. — By endemic, from w "in," and %to S , "the 

people," is , here meant that influence which gives character to the 

diseases of any locality, the term implying that it originates in the 

locality or among its inhabitants or people. It is evident that an 

o 



34: OF DISEASE. 

endemic influence consists of the sum total of all the pernicious influ- 
ences which are operating upon the health of the community in any 
locality referred to. In order then to arrive at the endemic influence in 
any locality, we should consider the climate, elevation, winds, soils and 
productions, as well as the cleanliness, morals, intelligence, prudence, 
&c, of its inhabitants ; and we may form an idea in our minds of a 
sort of compound endemic influence, which may not very generally be 
erroneous, and perhaps never so, if we could appreciate exactly all the 
influences which are operating. 

This, in my opinion, constitutes all there is in an endemic influence ; 
and the indications for its removal, or alleviation, consists in correcting, 
as far as may be corrected, all the natural influences by ditching, 
draining, cultivating, &c. ; and also securing to the inhabitants, cleanli- 
ness, temperance, virtue, industry, cheerfulness ; and in short, a strict 
observance of the laws of health in every respect. 

Epidemic Influence. — By epidemic, from tin, "upon," and %to$, 
"the people," is meant as the term implies, an influence coming upon 
the people more extensive in its effects than an endemic, and liable to 
extend, as some have done, nearly or quite around the globe. 

Various theories have been formed to account for epidemic influences, 
most of which have placed the cause in some mysterious principle beyond 
the power of man to reach or modify ; as though the Almighty had 
placed us here, and let loose upon us occasional emissaries of destruc- 
tion without our fault or even ability to palliate or resist. 

Now this may be so ; but I incline to the opinion, that more light on 
this subject and a more careful observation of the causes of disease 
generally, will yet bring home to us the unpleasant fact that the impru- 
dences of mankind in deviating from the laws of health, produces the 
predisposition to epidemics, as well as to all other diseases ; and that the 
elements in nature, which appear to act as causes of disease, are gene- 
rally, if not universally so, in consequence of this predisposition, the 
result of man's imprudence. If this be so ; we have, in order to 
ascertain the constituents of an epidemic influence, to take into account 
all the imprudences of the people, as far as the influence may extend, 
and then add to this the pernicious influences, which the various elements 
in nature, are unnecessarily allowed to exert upon them ; and we shall 
have formed in our mind, if we have exactly appreciated all the influen- 
ces, a correct notion of the epidemic influence. 

If this be so, it may account for the fact that in nearly all epidemics 
the first cases are the most fatal. For it is well known that epidemics, 
as a rule, sweep off the more intemperate portions of the human family ; 
and as those most predisposed by intemperance, would in that view of 
the case, be the ones first attacked, so would also such cases be more 
certainly fatal. 

SECTION III.— SYMPTOMS OF DISEASE. 

By syynptoms of disease, I mean here the phenomena developed by 
disease in any organ or function of the human body ; which may be sen- 
sible to the patient, or perceptible to a careful observer. I need not say, 



SYMPTOMS OF DISEASE. 6b 

that it would be impossible to give in this place, more than a general 
view of the symptoms of disease. And as I shall consider inflammation in 
the following chapter, and the phenomena of fever in the third chapter, I 
shall pass over the symptoms of inflammation and fever generally, alto- 
gether in this place ; and will confine myself here to a consideration of 
the general symptoms developed by the nervous system, the digestive 
system, the circulatory system, the respiratory system, by the eye, the ear, 
the skin, the urinary organs, and the genital organs. 

Neither shall I attempt to give the particular symptoms peculiar to 
each disease, with which the different parts of these various systems are 
liable to be affected ; but only such general symptoms as might not ne- 
cessarily be called up, when we come to treat of these diseases. By thus 
taking in this place such a view of the general symptoms developed by 
these various systems, in a state of disease, I trust that the particular 
symptoms may be more readily appreciated, when we come to take up 
particular diseases in their proper order. 

Before proceeding to inquire into the general symptoms developed in 
the human system in a state of disease, it is proper to bear in mind the 
anatomy and physiology of the human body ; and also to remember the 
relations of the different parts, as well as the phenomena exhibited in 
health, by comparison with which, the phenomena or symptoms developed 
in disease, will be more readily appreciated. Almost any person of 
common observation will readily detect variations from a state of health, 
by the countenance, jiositions, motions, mental conditions, restlessness, 
irritability, &c. of persons with whom they associate ; and I need not say 
that the general symptoms thus developed, in all variations from a heal- 
thy condition, should always be carefully noticed by the medical man. 

Symptoms Developed by the Nekvous System. — As the brain, and 
whole nervous system is the medium through which the mind communi- 
cates with the body, or the part upon which the mind directly acts, and 
as it is the medium through which we experience pain, the minute nerves 
pervading every tissue, transmitting impressions from every part to the 
mind, and carrying again the influence of the will to the voluntary mus- 
cles of every part ; we can see that its symptoms from diseased action 
must be very numerous and peculiar. It should also be remembered that 
the brain is the generator of a vital force, or nervous influence, which 
being transmitted through the nerves, enables the different organs of the 
body to carry on their functions. It is also through the nervous system, 
that the mind becomes conscious of pain and tenderness. 

The brain and whole nervous system, however, depend upon a due 
amount of stimulus from the blood to enable them to carry on their 
functions in a proper manner. It is evident then that diseases of the 
nervous system develop a train of symptoms which may exhibit them- 
selves through every organ and tissue of the body. I will here, how- 
ever, speak only of the general symptoms which attend an augmented or 
increased action, and a diminished action, and attempt to show the 
general phenomena of each. 

Increased action of the nervous system, if it be moderate, is attended 
with increased activity of all the functions of the body ; the increased 
amount of nervous influence exciting the digestive process, accelerating 



36 OF DISEASE. 

the circulation, increasing respiration, giving lustre to the eye, delicacy 
to the ear, a glow of health to the skin, activity to the urinary and 
genital organs, and increased activity to the mental faculties. 

If, however, the increased action becomes very great, instead of having 
the pleasant train of symptoms I have enumerated, there is developed a 
frightful train. 

The functions of the digestive system become interrupted or impaired, 
the respiration becomes rapid, the circulatory system becomes tumultu- 
ously excited, the eyes become red and glassy, the ear becomes painfully 
sensitive to sounds, the skin may become dry and hot, the urinary 
secretion is nearly suspended, the patient becomes wakeful, restless and 
delirious, the wildest insanity may occur, the cephelaga becomes intoler- 
able, and if serious organic changes occur in the brain, the patient dies 
either in a state of intense agony or passes into a fatal coma and thus 
expires. Such, according to my observation, are the general symptoms 
developed in cases of increased morbid action in the nervous system ; 
including of course organic changes in the brain itself. 

Diminished action of the nervous system, on the other hand, is 
attended with diminished action in all the functions of the body. The 
digestive organs become inactive or inefficient, respiration becomes 
defective, the circulation becomes languid, the eye becomes dull and 
heavy, the countenance becomes drawn and sallow, the skin is pale and 
exsanguinated, the functions of the urinary and genital organs are 
morbidly deranged, the intellect becomes dull ; and all the motions of 
the patient indicate a condition of languor, inactivity and gloom. If, 
however, the nervous depression is very great, all these general symptoms 
become very much aggravated ; digestion is nearly suspended, respira- 
tion becomes hardly perceptible, the blood recedes from the extreme 
vessels, and internal congestions or passive inflammations occur ; the 
countenance becomes pale and haggard, the muscles become thin and 
flabby, the mind becomes irritable, gloomy and hypochondriacal ; all the 
energies of the system become exhausted, and the patient restless, and 
dragging himself down in bed, either in a state of muttering delirium or 
profound coma, expires. 

With this general view of the symptoms developed by increased and 
diminished morbid action of the nervous system, we may be able to keep 
in our minds, as we take a glance at the general symptoms developed by 
the other systems of the body ; the important agency of the vital force, 
or nervous influence, in almost every symptom that is developed in every 
organ and tissue of the body. 

The position of the patient in cases of disease of the nervous system, 
attended with increased action, is apt to be very uncertain or changeable ; 
now assuming this attitude, and presently that, the motions in many 
cases becoming furious ; but in diseases of the nervous system attended 
with depression, or diminished nervous action, the patient is apt to lay 
upon the back, and in cases of great prostration to drag down towards 
the foot of the bed. 

The countenance again in cases of increased action of the nervous 
system is apt to become flushed, and if it becomes very great the eyes 
may become wild and glassy. In cases of diminished action or depres- 



SYMPTOMS OF DISEASE. 37 

sion, however, of the nervous system the countenance is generally pale, 
the eyes sunken and heavy, and there is a general expression of gloom ; 
but the most prominent trait of the countenance marking nervous depres- 
sion, is a leaden colored streak under the eyes ; first named I believe, by 
M Jadelot, "the oculo-zygomatic trait." 

This peculiar trait I have more especially noticed in patients whose 
nervous systems have become greatly depressed by licentious habits ; 
whether from masturbation, onanism or excessive sexual indulgence. I 
speak of this peculiar trait, as an observance of it is often of great 
value in affording a clue to the causes which may have been operating to 
produce the nervous depression ; especially as patients are often in such 
cases slow to confess or even to admit the truth. 

With this glance at the general symptoms developed by the nervous 
system, let us pass on to the consideration of the general symptoms 
belonging to the digestive system ; remembering that every disease in all 
the sj^stems, organs, or structures of the human body, must necessarily 
be attended with morbidly increased or diminished action of the nervous 
system. 

Symptoms Developed by the Digestive System. — The symptoms 
developed in diseases of the digestive system, are exhibited by the 
tongue, appetite, thirst, nausea, appearance of the alvine discharges, 
pain, position, countenance, &c. 

In most cases of excitation, whether inflammatory or from irritation, 
attended with increased morbid action of the nervous system, there is 
liable to be a red, dry, or coated tongue, loss of appetite, thirst, nausea, 
vomiting, diarrhoea, &c. ; the functions of all the organs of the body 
affected sympathetically, being morbidly excited, and more or less per- 
verted. In most cases of depression, in diseases of the digestive system, 
there is liable to be a flabby, and perhaps a darkly-coated tongue, loss 
of appetite, with colic, and perhaps acid eructations, colliquative diar- 
rhoea, internal congestions, wasting of flesh, and finally, a depressed ac- 
tion of all the organs of the body, and especially of those parts which 
sympathize more directly with the digestive system. 

The position of the patient in diseases of the digestive system, attended 
with inflammatory action, is generally rather stationary ; but little mo- 
tion being apparently desirable, as it usually increases the pain and 
general uneasiness. In spasmodic affections, however, unattended with 
inflammation, the patient is apt to be tossing about on the bed, as the 
motion evidently affords partial relief. Perhaps the most marked posi- 
tion assumed, is that upon the back, with the limbs drawn up, in cases 
of general inflammation of the peritoneum and abdominal viscera. 

The countenance, in diseases of the digestive system, is either flushed 
or pale ; is liable to have a sallow, greasy, or yellowish cast, and to have 
a general expression of gloom or despondency. There are, also, a few 
particular traits which should always be noticed ; such as the blueish 
color of the white of the eye, in diseases of the spleen ; the yellowish, 
in diseases of the liver ; the paleness around the mouth, in gastrointes- 
tinal inflammation or irritation ; and the peculiar gloomy expression 
usually exhibited, if the duodenum be the seat of the intestinal inflam- 
mation. 



38 OF DISEASE. 

It is hardly necessary to state, in conclusion, that the sympathetic 
disturbances in the functions of all the organs of the body, from diseases 
of the digestive system, are very considerable, depending, however, 
upon the seat, nature and extent of the disease, and also upon the sym- 
pathetic relation of each organ with the diseased part, &c. 

Symptoms Developed by the Respiratory System. — The general 
symptoms developed by diseases of the respiratory system are dyspnoea, 
cough, expectoration, and the sounds elicited by auscultation and per- 
cussion, as well as the positions assumed, countenance, &c. In spasmodic 
affections of the respiratory system, attended usually with diminished 
nervous action or energy, the dyspnoea may be very considerable ; the 
cough is apt to be hollow and dry ; in many cases there is no expectora- 
tion ; and the sympathetic disturbances of the system depend upon the 
seat and severity of the local spasmodic affection. 

In inflammatory and organic diseases, generally, the dyspnoea is liable 
to be considerable ; the cough, in the early stages dry, is apt to be 
attended, in the latter stages, with a mucous, bloody, or purulent expec- 
toration ; and the sympathetic affections or disturbances, in the func- 
tions of the various organs of the body, are always more or less con- 
siderable. In no class of diseases is the necessity of inquiring into the 
condition of the nervous action or energy more important than in dis- 
eases of the respiratory system, whatever may be the seat, or apparent 
character of the disease. This is rendered so, from the liability of pas- 
sive inflammation, to which the lungs especially, by the character of their 
structure, are peculiarly predisposed. 

The positions assumed in diseases of the respiratory system, depend 
upon the nature and seat of the disease. In pneumonia, if but one lung 
be involved in the inflammation, the patient lies on the affected side ; if 
both, the patient lies on the back, with the shoulders elevated. In 
pleurisy, the patient lies on the well side, as it creates less pain ; while 
in bronchitis the patient generally lays on the back, with the shoulders 
considerably elevated. 

The countenance, in this class of diseases, varies with the seat and 
nature of the disease. In pneumonia, the face is livid, and has an 
anxious expression ; in bronchitis, the face is pale, and the countenance 
exhibits a hurried aspect ; while in tubercular phthisis, the countenance 
has the hectic flush, and wears a hopeful expression. With this general 
glance we will pass on to the consideration of the general symptoms 
developed in diseases of the circulatory system, leaving the consideration 
of the sounds elicited by auscultation, percussion, &c, till we come to 
take up the special diseases of the respiratory system, in a succeeding 
chapter of this treatise, in their proper place. 

Symptoms Developed by the Circulatory System. — The symp- 
toms developed by diseases of the circulatory system, include the actions 
of the heart ; the frequency, quickness, volume, tension, and strength 
of the pulse, the condition of the veins and capillaries, and the state of 
the blood. 

It is proper to remember that the pulse of a new-born infant beats 
from 130 to 150 times per minute ; that of a middle aged person, from 
70 to 80, while that of the aged, may vary from 50 to 70. It should 



SYMPTOMS OF DISEASE. 39 

also, be borne in mind, that sex, position, and various accidental circum- 
stances are liable to vary the frequency of the pulsations considerably 
from this standard, which circumstances should always be noticed and 
taken into the account. 

In functional diseases of the circulatory system, attended with in- 
creased or exalted nervous action, the pulse is liable to be frequent, 
quick, tolerably strong and tense, while in functional diseases, attended 
with diminished nervous action, or depressed vital power, the pulse may 
more generally be frequent, and perhaps quick, but it is likely to be not 
very strong or tense. The pulse, in inflammatory diseases of the circu- 
latory system, if the inflammation be active, may be frequent, quick, 
full, tense and strong ; if however, the inflammation be passive, being 
attended with depression of the vital power, the pulse may be frequent 
or slow, but it is not generally very strong or tense. Finally, in organic 
diseases of the circulatory system, whether the disease be of the heart 
or arteries, the pulse is liable to become very irregular and in most cases 
intermittent. 

The capillary and venous circulation correspond in most cases with 
the cardiac and arterial, while the state of the blood which should 
always be examined when drawn, by the microscope if necessary, will 
generally be found weak or strong, according to the exalted or dimin- 
ished action of the nervous system. Why this is generally the case, we 
need not wonder, when we remember that the blood enables the brain 
and nervous system to generate and distribute the nervous influence or 
vital force. 

The 'positions assumed in diseases of the circulatory system, are, some 
of them peculiar. In hydropericardium and hydrothorax, the patient 
is found with the head and shoulders considerably elevated ; or in hydro- 
thorax, if the fluid occupies but one side of the chest, the patient may 
be found lying on the affected side, in some cases. 

The countenance in dropsical cases has a bloated or tumid appearance, 
and in cases of organic disease of the heart, attended with considerable 
interruption to the circulation through the lungs, the countenance wears 
an anxious expression, and sometimes there may be seen a pale or leaden 
colored line, extending from the angles of the lips to the margin of the 
chin. This trait of the countenance, so significant of organic disease 
of the heart, has been called "the labial trait." 

The sympathetic derangement of the various organs of the body, with 
diseases of the circulatory system, are very considerable, and as the 
arteries, veins and capillaries penetrate every organ and tissue of the 
body ; general diseases of the circulatory system, as well as of the nerv- 
ous system, must necessarily involve more or less, every organ and 
tissue of the body. 

Symptoms Developed by the Eye. — The symptoms developed in 
diseases of the eye, are pain, redness, intolerance of light, or want of 
sensitiveness to light, &c, depending upon the nature of the disease. 
In active inflammation of the organ, attended with increased action or 
excitation of the nervous system, there is apt to be intolerance of light, 
pain, redness, and more or less cephalalgia, &c. ; but in passive inflamma- 
tory ophthalmia, attended with diminished nervous action, or vital depres- 



40 OF DISEASE. 

sion, there may be intolerance of light, pain and redness, but in addition 
to these symptoms, the cornea is apt to present a cloudy appearance. 

In amaurosis, a disease depending upon diminished vital action in the 
optic nerve, and attended in many cases with general nervous depression, 
the eye may appear to the observer, nearly natural, but the patient ex- 
periences partial or total loss of sight, and the disease may or may not 
be attended with pain. In organic diseases of the eye generally, the 
appearance of the eye usually indicates the nature of the organic changes. 

Exophthalmic*,) or a protrusion of the eyes from their sockets, depend- 
ing upon general debility, with relaxation of the muscles of the eye, and 
a congested condition of the tissues in the back part of the orbit, forming 
the cushion of the eye, is usually a disease of females, though very rare ; 
and so far as my observation has extended, it usually occurs in connection 
with bronchocele, in anaemic females, suffering from amenorrhoea. The 
protrusion of the eye-balls, in some cases giving the appearance of en- 
largement, is liable to deceive the careless observer ; but by careful 
attention to all the symptoms, together with the complications, the nature 
of the disease need not be mistaken. 

The position assumed by the patient with ophthalmia, is liable to be on the 
back, with the head slightly elevated. The countenance in this class of 
diseases, is well understood by every observer ; but the countenance and 
position in walking, in children, with scrofulous ophthalmia should be 
born in mind ; especially the bowing or bending forward of the head, and 
squinting through the eyebrows. The sympathetic disturbance of the 
different organs, with diseases of the eye, are very considerable, the 
brain however, being the part more especially involved, in most cases. 

Symptoms developed by the Ear. — The symptoms developed in 
diseases of the ear, are a sense of roaring, pain, intolerance of sound, 
and deafness, &c. In cases of inflammation of the structures of the 
middle and internal ear, attended with nervous excitation, or increased 
nervous action, there is pain, more or less severe, intolerance of sound, 
with great acuteness of hearing, in some cases, and generally severe 
sympathetic cephalalgia. In cases of otitis, attended with nervous de- 
pression, the pain may be in some cases dull, and not unfrequently there 
is dullness of hearing, or even deafness. 

If wax has accumulated in the meatus auditorious to any considerable 
extent, it is apt to produce a sense of roaring, and it is hardly necessary 
to say, that a loss of action in the auditory nerve, produces nervous deaf- 
ness. The position of the patient in otitis, is apt to be very changeable, 
and the countenance is apt to be indicative of pain and anxiety. It 
should also be remembered, that while the different organs of the body 
may sympathize more or less with diseases of the ear, the brain has the 
most intimate sympathetic relation. 

Symptoms Developed by the Skin. — The general symptoms devel- 
oped by the skin, are its temperature, moisture or dryness, color and a 
class of rashes and eruptions. In cases of great debility, the skin is apt 
to be pale, cool, and in some cases, it is covered with a clammy perspira- 
tion. In sthenic conditions, attended with increased action of the ner- 
vous and circulatory function, the skin is flushed and warm, and in most 
cases dry. A great variety of rashes and eruptions appear upon the 



SYMPTOMS OF DISEASE. 41 

skin ; some of them indicative of the exenthematous fevers ; while others 
are more local affections of the skin. Especially is this the case with the 
animalcular and crjptogamous eruptions ; for a clear diagnosis of which 
the microscope becomes of great value. 

The position of the patient in exanthematous affections is apt to be 
very changeable, on account of the intense itching which is liable to 
attend : and the countenance, so far as it is changed, is indicative of that 
very peculiar sensation ; the face of course being marked by the rash or 
eruption in many cases. The different organs, structures, and tissues of 
the body are liable to suffer by sympathy, in many diseases of the skin ; 
and while the mucous membranes generally suffer most, the alimentary 
mucous membrane is especially liable to suffer, so far as my observation 
has extended. 

Symptoms Developed by the Urinary Organs. — The general 
symptoms developed in diseases of the urinary organs, include those 
attending diseases of the kidneys, ureters, bladders, and urethroe ; and 
also the quantity and quality of the urine, as well as the manner of its 
discharge. 

In inflammatory diseases of the kidneys, there is apt to be a dull, 
heavy pain ; if, however, the ureters, bladder, or urethrae be the seat of 
the inflammation, the pain may be acute, and of a biting or stinging 
character. In neuralgic affections of the urinary organs, the pain is 
sharp and acute, as in neuralgia generally. 

The quantity of urine in inflammatory affections of the kidneys is 
usually small ; and if the ureters, bladder, or urethra be involved in the 
inflammation, there is liable to be difficulty, with more or less pain, in 
voiding it. 

In nervous diseases of the urinary organs, if attended with general 
diminution of vital force, the quantity of urine secreted may be morbidly 
increased, and there may be incontinence ; or, if the disease be of the 
urinary passages, and spasmodic, there may be temporary retention of 
urine. 

In albuminuria, or granular disease of the kidneys, and perhaps in 
other forms of organic disease of these glands, the urine is liable to be 
charged with albumen, which may be detected by exposure to heat. 
The urine is liable also to contain acid or alkaline substances, depending 
generally upon an excess of acids or alkalies in the fluids of the body ; 
and these substances may cohere or unite in the urinary passages, and 
form stone in the cavity of the kidneys or bladder ; or they may be sus- 
pended in the urine till it is voided, and then it may separate and form 
a sediment in the vessel, if allowed to stand. 

Bile and various other ingredients, not found in healthy urine, may be 
separated from the blood by the kidneys ; rendering an examination of 
the urine, in most diseases, as by heat, the microscope, etc., if necessary, 
a matter of great importance. 

The position assumed by patients with nephritis is peculiar, the body 
being usually bent forward ; and if but one kidney be involved, being 
turned a little to the affected side. The countenance is not very peculiar, 
though, in addition to the expression of pain, when it exists, the face is 
apt to have a dingy, bloated appearance, in some cases at least. 



42 OF DISEASE. 

The sympathetic relations existing between the kidneys and the various 
organs of the body are very general ; but the stomach appears to sym- 
pathize, perhaps more strongly, than any other part — considerable nausea 
and vomiting usually occurring in cases of nephritis. There is, however, 
a strong sympathy between the urinary and genital organs, as we should 
naturally suppose, from their immediate connection. 

Symptoms Developed by the Genital Organs. — The general symp- 
toms developed in diseases of the genital organs, of course vary with the 
sex. In males, they differ with the nature and seat of the disease, and 
depend, also, in many cases, upon the general conditions of the system. 
In inflammatory diseases of these organs in males, attended usually with 
increased action of the nervous and circulatory functions, there is liable 
to be pain, more or less severe ; and in many cases there is a morbid 
excitation of function, with or without seminal or other discharges. In 
cases of mere irritation, however, with debility of the organs, and per- 
haps attended with a general depression or diminished vital action, there 
may or may not be pain or any abnormal discharges ; but in too many 
cases, if some form of licentiousness has been practiced, there is liable 
to be morbid seminal or other discharges. 

The general symptoms developed in diseases of the genital organs in 
females are either inflammatory, organic, or nervous ; and the symptoms, 
of course, depend upon the nature, seat, and character of the disease. 
In inflammatory and organic diseases generally, there is apt to be pain, 
tenderness, and in many cases a morbid discharge ; while in nervous 
diseases, attended with local and general debility, if there be pain, it is 
of a sharp, darting character. Suppression or retention of the menses, 
as well as uterine hemorrhages, may be connected with a sthenic or 
asthenic condition of the system ; the local and general disease being in 
the one case active, and in the other passive; depending generally upon 
the state of the blood, and also upon a consequent increased or dimin- 
ished action of the nervous system. 

The positions assumed and expressions of countenance in diseases of 
the genital organs are not very particular, if we except hysterical affec- 
tions, in which disease the patient is either tossing about, or else laying 
apparently almost lifeless : the countenance in the one case exhibiting 
the wildest excitement, while in the other it is much as in profound sleep. 

The sympathetic relations of the genital organs with the other organs 
of the body are very general, especially in the female ; sympathetic dis- 
turbance of the nervous system being, as I believe, the cause of most 
of the phenomena of hysteria. 

Having thus taken a glance at the general symptoms developed in 
diseases of the nervous system, the digestive system, the respiratory 
system, the circulatory system, of the eye, of the ear, of the urinary and 
genital organs, we are prepared to pass on to the consideration of the 
diagnosis and treatment of disease, in the two succeeding sections of this 
chapter. Before, however, we leave this subject, it may be well to re- 
member that pain depending upon inflammation, in the structures gene- 
rally, is apt to be continuous, and more or less increased by pressure ; 
while spasmodic pain is often intermittent, and may be more or less 
relieved by pressure. 



DIAGNOSIS OF DISEASE. 4o 

It is also proper to remember here, as of general application, that in 
inflammation of the serous membrane, as in the pleura, the pain is lan- 
cinating ; in the fibrous structures, it is dull ; in the nervous, darting and 
acute ; while in the parenchymatous and cellular, generally, it is apt to 
be dull, throbbing, and heavy. 

Thus have I completed what I had to say here on the general symp- 
toms of disease ; leaving the particular symptoms to be called up when 
we come to take up the particular diseases of the various organs and 
structures of the body, in their proper place. 

SECTION IV.— DIAGNOSIS OF DISEASE. 

Br diagnosis, from Sea, and yuuoaxa, 4 I know,' is here meant to know or 
discriminate : hence, by diagnosis of disease, is meant tolrnow or discri- 
minate disease ; and as disease consists merely in a deviation from the 
standard of health, diagnosis is really ascertaining the deviations from a 
state of health. It is true that various names have been given to 
these deviations ; and hence, we say, this and that disease. With this 
explanation, we are prepared to pass on to a consideration of the diag- 
nosis of disease. It is proper, however, to state, before we proceed, that 
the term diagnosis is used technically ; not only to know disease, but also 
to distinguish one disease from another. 

Now from the very nature of the case, it is absolutely impossible to 
form a correct diagnosis of disease, without a knowledge of anatomy and 
physiology. For how can we arrive at a deviation from a state of health, 
without first knowing what a healthy condition should be ? In fact, at- 
tempting to form a correct diagnosis or notion of disease without a pre- 
vious knowledge of the human system, and of the nature and operations 
of its functions, would be just as absurd as it would be for a man, unac- 
quainted with the machinery of a watch, to attempt to account for any 
failure in its keeping correct time. 

With a correct understanding, however, of anatomy and physiology, 
and of the causes of disease, as well as of the means of preserving health, 
the man of good common sense may generally form a correct diagnosis ; 
thus making pathology, or " diseased physiology," to the close observer, 
a plain matter of common sense ; following as plainly as any effect fol- 
lows a cause. With these preliminary considerations, we are pre- 
pared to pass on to the consideration of the best manner of forming a 
diagnosis ; by the history of the case ; an examination of the symptoms, &c. 

Calls. — It is hardly necessary to say, that calls to attend the sick 
should always be attended to without delay ; even in cases not apparently 
alarming. For it shows a reasonable desire on the part of the physician, 
to gratify the feelings, at least, of the patient ; and it leaves the doctor 
at leisure to attend important calls which require haste, should they be 
received. While, then, great haste and bluster should not be exhibited, 
due promptness is always commendable; and is often a matter of great 
account in the mind of the patient. 

Question the messenger. — In calls to visit the sick, it is generally 
proper, especially in the country, to inquire of the messenger who is 
sick, and what appears to be the matter. This enables the pbj-sician to 



44 OF DISEASE. 

prepare himself with whatever he may be likely to need, by way of in- 
struments, medicines, &c. ; a consideration of importance to country prac- 
titioners at least. Besides, if the messenger is an intelligent person, the 
answers may enable the physician to calculate, with some degree of cer- 
tainty, at what time he may be able to return. And further, indefinite 
as such answers must always be, they may afford a clue to a correct diag- 
nosis in the case. 

Inquire of the Friends. — When a very sick patient is visited for the 
first time, I think it is generally well to inquire of the friends or family 
in relation to the case, and, if possible, to get from some one of them a 
general history of the case. This enables the physician to come directly 
at the important particulars in a manner to give the patient the least 
possible worriment. This is especially important if the patient be a 
child, or a very sick adult. In adults, however, if the patient is not 
very sick, it may not be necessary, or even advisable. 

Examination of the Patient. — In the examination of the patient, it is 
best to ascertain the age, occupation, and residence, if not already known. 
The age enables the physician to appreciate any influence that particular 
periods of life may be exerting — an item of importance in many cases, in 
female patients, at the age of puberty, or at the critical period of life. 
The occupation, too, may have had an important bearing in modifying 
or even producing the disease. The residence enables the physician to 
appreciate any endemic or local influence w r hich may have produced or 
modified the disease. All these circumstances being taken into account, 
the examination may be proceeded with in a rational manner. 

In all cases, it is best next to inquire how long the patient has been sick 
or poorly, and to get from the patient a history of the case. It may be 
best, however, to interpose questions, to ascertain facts and circum- 
stances which may not appear clear, from the account of the patient as 
he proceeds with the history, as it keeps up a continuous chain of circum- 
stances which otherwise might appear broken or indefinite. 

Having thus got a history of the case, it is best to inquire into the 
causes which may have been operating, as it may, in part, account for 
the first deviation from health ; and it may also account for many pe- 
culiarities in the history of the case, which might otherwise be compara- 
tively unaccountable. In many cases the patient may have formed cor- 
rect notions as to the cause of his sickness ; if not, an inquiry into the 
habits of the patient may enable the physician to, at least. 

In chronic or acute cases of disease, having proceeded thus far, it is 
best to mark the countenance, position, and motions of the patient ; and 
having appreciated whatever they may indicate, a general examination 
of the organs and functions of the body should be made, beginning, in 
chronic cases, with the brain and nervous system, and passing on to the 
digestive, respiratory, and circulatory systems, and, if necessary, in- 
quiring into the condition of the eye, ear, and skin, as well as of the 
urinary and genital organs. 

In very acute diseases, the attention may be at once fixed upon the 
diseased organ or part, in which case it may be best to examine that 
part first, and then to notice the complications involving the other parts, 
organs, or functions of the body. This would relieve the patient from 



DIAGNOSIS OF DISEASE. 45 

too much woniment, and might be amply sufficient, in many acute 
diseases, especially in cases in which the natural complications with the 
local disease might readily be inferred. 

In examining cases it is best to ascertain if there be pain or tender- 
ness, and also the character of the pain, if it be experienced. This is 
of great importance in cases of disease affecting mainly internal organs, 
and should, therefore, never be omitted. The absence of pain, or even 
tenderness, should not, however, be considered as an evidence of the 
absence of disease, or of inflammation in all cases. 

The pulse should be examined to ascertain the condition of the circu- 
latory system, and it is always proper to note the frequency of the pulsa- 
tions, as well as the quickness, volume, tension, strength, regularity, &c, 
as indicative of the power of the heart and arteries, and, indirectly, of 
the degree of vital power. In making an examination of the pulse the 
arm should lie in a semi-flexed position, and two or three fingers being 
placed gently upon the radial artery, the pulsations should be noticed for 
a minute at least. 

Having thus ascertained the age, occupation, and residence of the 
patient, when not previously known ; and also learned the time of attack, 
as well as the history of the case ; and noticed the countenance, position, 
and motions of the patient ; and inquired in relation to the pain and ten- 
derness ; and, lastly, having examined the pulse, the attention should be 
turned to the part or parts in which the disease appears to be located — 
and I need not say that every symptom which can have a bearing upon 
a correct diagnosis, should be carefully inquired into and appreciated. 

In completing the examination, a careful inspection of the diseased part, 
as well as palpation in various ways, may become necessary. In many 
cases, also, pressure, succussion, percussion, auscultation, mensuration, 
and chemical, as well as microscopical examinations may be required, 
depending, of course, upon the nature and seat of the disease. 

Having thus ascertained the seat and nature of the disease, in the 
manner I have suggested, it becomes a matter of great importance to 
estimate correctly the degree of vital force, or the amount of nervous 
energy which remains. For by taking into account the degree of nerv- 
ous influence generated by the brain, and distributed by the nerves, a 
correct conclusion may generally be formed as to whether the disease be 
of an active or passive character, or in other words, whether it be 
attended with augmented or diminished action of the nervous system. 

Finally, when a correct diagnosis has thus been arrived at, whether 
the disease be of some part of the nervous, digestive, respirator?/, or cir- 
culatory systems ; or of the eye, ear, skin ; or of some portion of the 
urinary or genital organs ; we should not only carefully arrive at the 
exact condition of the diseased part, but we should estimate correctly, 
not only the sympathetic relations, but should also discriminate care- 
fully between sympathetic disturbance and primary disease. 

Thus have I completed what I had to say here on the diagnosis of dis- 
ease ; and I hope that the suggestions here made may be sufficient to 
put the student upon the right track ; that when he comes to assume the 
f earful, responsibility of examining and prescribing for the sick, he may 
feel no embarrassment in relation to the best method to be pursued. I 



46 



OF DISEASE. 



will, however, in conclusion again suggest the importance, when necessary, 
of microscopic examinations, especially of the saliva, milk, blood, pus, spu- 
tum, vomited matters, foeces, &c. It is necessary, however, in order to ap- 
preciate an abnormal appearance of these, or any other secretion or excre- 
tion, &c, to understand their normal appearance in a state of health. 
Thus does the evidence afforded by the microscope become a plain mat- 
ter of common sense, as well as the evidence afforded by every symptom 
which it becomes necessary to examine, in forming a diagnosis, for the 
purpose of arriving at the indications in the treatment of disease. 

Having now taken a glance at the nature, causes, symptoms, and 
diagnosis of disease, I shall proceed, in the following section, to take 
into consideration the treatment of disease, which will complete this 
chapter on disease. 

SECTION Y.— TREATMENT OF DISEASE. 

By treatment of disease, or therapeutics, I mean here, to attend upon 
or alleviate the sick; and also the modus operandi oFremedies, as well as 
the rules for applying them, &c. I wish however, to offer only a few 
general suggestions here, and will therefore consider, first, the duties of 
the physician in attending upon the sick, and will then inquire into the best 
method of fulfilling indications, &c; and, lastly, give some general rules 
which may serve as a guide in administering or applying remedies, &c. 

To attend upon the sick is one of the most responsible positions in 
which a man can be placed. The physician, then, should be a man of 
strict morals, stern integrity, good education, and withal, a man of good 
common sense. With these essential qualifications he stands forth 
among his fellow men, a teacher of righteousness, second to no man, or 
class of men, not even the clergy excepted. The physician, then, thus 
qualified — and let none other assume to be such — offers his services 
directly, by inserting a notice in a paper, or indirectly, by placing a 
sign at his door, it matters not which. In either case he is responsible 
to the community for the faithful performance of his duties. 

The duties of the physician thus qualified and situated, are substan- 
tially these : — To observe himself, and teach others, so far as he is able, 
the Laws of Health, so that people may never get sick, if he can help it. 
To use his best endeavors, when called on, in case of sickness, to have 
the invalid restored to health as soon as possible. And, finally, to 
give such advice to all his patients as shall enable them, as far as possi- 
ble, when once restored to health, to keep well. 

Now in relation to the best method of giving advice to the community, 
that they may avoid getting sick, as well as to the advice proper for each 
patient restored, that they may avoid further sickness ; I will leave it to 
the good sense of my fellow students of the Medical Profession, and will 
only offer a few suggestions in relation to the treatment of the sick ; or 
as I have termed it, the treatment of disease. As then I have already 
suggested, in a previous section, that a correct diagnosis should always 
be formed, so that the Physician may have a correct understanding of 
the disease of his patient, or of the deviations of his system from a state 
of health ; so nothing should be prescribed, as a remedy, without first 
getting a clear Indication. 



TREATMENT OF DISEASE. 47 

Indications. — By indications, I mean any manifestation offered by 
disease ; of what is proper for its removal. Indications then may point 
to any remedial measure, such as removing the cause of the disease, 
correcting bad habits, exercise, fresh air, cheerfulness, and in fact, to 
any and everything, that could tend to restore health. When then 
indications are once discovered they should be fulfilled, and in just so far 
as they can be, without the administration of medicines. For medicine, 
it should be remembered, is at best little better than a necessary evil. 
It is then for the good sense, of every medical man, to judge how far he 
can fulfill the indications, furnished by the condition of the patient, 
without the administration of drugs. It is certain, however, that just 
so far as it can be done, by removing the causes, correcting bad habits, 
regulating the diet, by exercise, cleanliness, cheerfulness, and in short, 
by enforcing a strict observance of the laws of health, it should be done. 
At any rate, I would never prescribe medicine for any patient, unless 
that which was indicated, in these respects, were strictly complied with. 

After doing, however, all that can be done of a hygienic character, if 
any indications remain to be fulfilled, medicines should be prescribed if 
they can be found exactly adapted to fulfill the indications. But before 
resorting to medicines, it is well to remember, that disease is always, in 
one sense, a condition of debility ; and that if depletion is ever required 
in the treatment of disease, it is only so to prevent a worse evil, and that 
it is always done at the expense of vitality even when it be imperatively 
required. It is well then to avoid depletion as far as it is consistent with 
the welfare of the patient ; but if a suffering organ require it, it must be 
resorted to, even though it be at the expense of the general strength. 

When there are indications which demand medicine, if it is possible to 
fulfill them by remedies that will not produce or leave a bad impression 
upon the fluids or solids of the system, such remedies should be used. 
And if the indications can be fulfilled by a remedy or medicine that will 
improve permanently the blood and general system, such remedies should 
by ail means be preferred and used instead. But to save life, when 
nothing short will do, it is right not only to deplete, but also to use 
remedies, the permanent effects of which may not be the most pleasant. 
This becomes a duty, as most people prefer to live, even though it be "at 
a poor dying rate." When, however, extreme measures become thus 
necessary, every possible precaution should be taken to administer them 
in such a way as to render them the safest possible ; and yet to fulfill the 
indications for which they are administered. 

Among the most prominent Indications that are liable to be presented, 
in diseased conditions, are, for depletion, repletion, dilution, stimulation, 
sedation, revulsion, suppression, alteration, chemical action, mechanical 
influence, Sj-c. ; concerning the proper fulfillment of which, it is well that 
we should consider, as we pass along. I will therefore take them up in 
the order in which I have named them. 

Depletion. — When depletion becomes necessary, if it can be done by 
cutting off the supply of food, it should thus be accomplished ; but if not 
and the abstraction of blood becomes necessary, the local should be 
resorted to if it will answer, but if not, and there is no other alternative 
general bleeding should be resorted to, to prevent a worse calamitv. 



48 OF DISEASE. 

Repletion. — If a tonic becomes indicated, in consequence of weakness, 
or poverty of the blood ; if a regulated and nourishing diet will correct 
it, with proper exercise, air, &c, that is the best prescription ; but if 
that is not sufficient, it is best to use in addition, such a tonic or tonics 
as will supply the blood and solids, with that in which they are deficient. 

Dilution. — If there be an indication to dilute the blood, it should 
always be done by pure water, or something not irritating to the alimen- 
tary mucous membrane, and which, on entering the blood will dilute it, 
without rendering it an irritant to the various tissues of the body. 

Stimulation. — If the indication is to stimulate, that may sometimes 
be accomplished by stimulating food, good air, cheerfulness, &c. ; but if 
that is not sufficient, it is well to resort to such a remedy as shall not 
irritate, or in any way permanently impair the tone, vigor, or functions 
of the system. 

Sedation. — If a sedative be indicated, let every source of excitement 
or irritation be carefully removed, and then, with soft words and gentle 
manners, allay excitability as far as is possible. If, however, these 
measures do not entirely fulfill the indications, use in addition, such a 
sedative as will quiet arterial or nervous excitability, without permanently 
impairing vitality or deranging the functions of the body. 

Revulsion. — If counter-irritation be indicated, it should be done by 
the most convenient, cleanly and effectual means ; always taking care to 
avoid unnecessary torture, as well as to prevent as far as may be, ugly 
scars, especially on the fair sex, or about the face in any case. 

Suppression. — If the indication is to suppress some morbid condition, 
as that of excessive fear, rational assurances should be held out of 
safety ; and that assurance once established, may entirely suppress or 
destroy the morbid state of fear. So, if an indication arises to produce 
a new morbid condition, in order to suppress some seated disease, care 
should always be taken that the morbid condition produced to cure the 
disease, be not worse than the original morbid condition. 

Alteration. — If alteratives are indicated, it is well to inquire just 
what alteration is needed, in the fluids or solids, or both ; and then to 
select the most safe, convenient, and reliable remedy, that will produce 
the alteration required, without itself in any way impairing vitality, or 
deranging any of the organs or functions of the body. 

Chemical action. — If the indication is for some chemical agent, as to 
neutralize an acid in the stomach, or to render harmless some poison 
taken into the stomach, care should be taken to select such an agent as 
combining with the irritant will produce a compound of the most harm- 
less character possible ; or, which if possible, shall itself act remedially. 
Thus, if a child has acid in the stomach, in such excess as to require 
neutralizing, if the bowels are constipated, soda may be indicated, be- 
cause uniting with the acid, a laxative salt is formed, which may regulate 
the bowels ; but, if on the other hand, the child has a diarrhoea, chalk 
may be indicated, because, uniting with the acid it forms a compound, 
slightly astringent, which itself may aid in correcting the diarrhoea. 

Mechanical influence. — When mechanical influences are indicated, 
such as position, compression, friction, &c. ; care should be taken that it 
be accomplished, with the least possible inconvenience to the patient, 



TREATMENT OF DISEASE. 49 

and that in fulfilling the indication, no other morbid condition be pro- 
duced, or if any, the least possible, under the circumstances. 

Having now finished what I had to say, on the duties of the Physi- 
cian, in attending upon the sick, and also, thrown out a few suggestions 
in relation to the best method of fulfilling indications, &c, it only re- 
mains for me to give some general rules in relation to medicines, and I 
am through with what I proposed to offer on therapeutics, or the treat- 
ment of disease. As then, we have already seen that diagnosis is essen- 
tial, in order to arrive at the indications in every case ; so a knowledge 
of Materia Medica, becomes an absolute necessity, in order to select 
remedies, to fulfill indications. I need not say then, that materia medica, 
should be studied with exquisite care, so that each remedy and class of 
remedies, shall be as familiar as the hours of the day. 

Materia Medica. — Various classifications of medicines have been 
attempted, in order to render the study easy and systematic. Among 
the classes into which medicines or remedies have been arranged, are 
narcotics, antispasmodics, tonics, astringents, emetics, cathartics, emena- 
gogues, diuretics, diaphoretics, expectorants, sialagogues, errhines, epis- 
pastics, refrigerants, antacids, diluents, and emolients, &c. Now, with 
a correct knowledge of each medicine or agent, included in the above 
classes, or in each list, of any other classification ; indications arising 
in any disease, will readily suggest the class from which the remedy is 
to be selected. Then, by running over in the mind, the medicines in 
that class, the particular medicine best adapted to fulfill the indication, 
may be selected and prescribed. 

Care should always be taken that none but genuine drugs be selected 
or used, as others might not only fail to fulfill the indications, but would 
also be liable to do positive injury. In administering medicines, they 
should be given as little combined as possible, and they should also be 
given in such a form as to be as pleasant to the taste as may be. And, 
in relation to the doses or quantity to be given at one time, if the cus- 
tomary dose is to be deviated from, in any case, I think it is generally 
best to give less, and then to repeat the dose if necessary, especially if 
the patient be a female, or of a slender constitution. 

In proportioning the dose to the age, the greatest possible care should 
be exercised, as carelessness in this respect might lead not only to a 
failure in the effect, but also, if too large a quantity be given, to the 
most serious consequences. A rule which I have always followed, and 
which, at least, has the advantage of convenience, is as follows : Divide 
the age of the patient by itself, increased by twelve, and the quotient 
gives the fraction of an adult dose that the child requires. 

Thus, if it be required to find the dose for a child three years old, add 
twelve to three, the age of the child, and we have fifteen for a dividend ; 
which, being divided by three, the age of the child, gives a quotient of 
five, showing that the dose for a child three years old is one-fifth of that for 
an adult. Now if the dose of the medicine to be given would be for an adult 
ten grains, the dose for the child three years old would be one-fifth of 
ten, which is two, thus showing that the dose of that particular medicine 
is two grains for a child three years old. The same rule will apply to 
any age, and no matter what the adult dose may chance to be. It is. 
4 



50 TREATMENT OP DISEASE. 

therefore, a good rule, and I would recommend its adoption and applica- 
tion in arriving at the dose for patients under twenty years of age, after 
which an adult dose may generally be required. 

Now I will only add a few suggestions in relation to frescr lotions, 
quiet of the patient, and food, and I am through with what I had to say 
on the treatment of disease in this place. 

P resolutions. — If prescriptions are written, they should be made 
plain, so that the druggist need not make a mistake ; and prescriptions 
should never be put up by any except careful, sober, responsible men, 
that proper drugs may be used, and due care be exercised in putting 
them up. If medicines are prepared by the physician, they should be 
left under the care and directions of a responsible nurse, that no mistakes 
may occur in administering them ; and the hours of administering them 
should be arranged as conveniently for the nurse as may be, and yet be 
the best possible for the patient for whom they are prescribed. 

Quiet. — Patients suffering from severe disease should be kept quiet, 
and not be disturbed by company any further than is absolutely neces- 
sary for the care of the patient. And as nurses and friends of the pa- 
tient are generally poor judges in relation to these matters, and as the 
responsibility of keeping out, in some cases, near relatives, is more than 
the nurse might, in all cases, be able to endure alone, I believe the phy- 
sician should give, in all cases in which it is necessary, imperative orders 
in relation to this matter, that may not be departed from, and thus se- 
cure the patient from destruction by intruding friends. 

Nourishment. — Now as disease is, in one sense, a state of debility, it 
is not best, as a general rule, to starve patients, even though they may be 
laboring under acute disease. For it should be remembered that if a 
person in health should go without food for several days, great pros- 
tration, with disturbance of all the functions of the body must be the 
result ; and, if the fasting be continued for a sufficient time, death is the 
inevitable result. If, now, this be so, how shall a patient, reduced by 
disease, endure to be deprived of food or nourishment ? The truth is, 
they will not endure it for any great length of time, and therefore, the 
experiment should not be tried. If then, as is often the case, there be 
no appetite for solid food, broths or milk, diluted with an equal part of 
toast water, may be given ; and as soon as the appetite returns for food, 
toast, or some other suitable form of food, should be given, at meal hours, 
through the whole period of convalescence. 



CHAPTER II. 
OF IRRITATION, CONGESTION AND INFLAMMATION. 



SECTION I.— IRRITATION. 

By irritation I m ean her e a morbid disturbance in the vital actions, in 
the whole or any part ofthe system, short of inflammation, involving 
primarily the nerves, and being attended with more or less pain. Irri- 
tation, then, may be associated with a sthenic condition of the system, 
attended with augmented or increased nervous action ; or it may occur 
in an asthenic condition, attended with diminished nervous action or 
depression of vital power. Or irritation may be comparatively local, 
not associated with any very marked general increased or diminished 
action of the nervous function, as in the case of local injuries, &c. I 
will therefore proceed to consider irritation under the heads of active or 
sthenic, passive or asthenic, and local, as being the most convenient. 

Active or Sthenic Irritation. — By active or sthenic irritation, then, I 
mean that which is attended with an active or sthenic condition of the 
system, or in which there is a general morbid augmented action of the 
nervous function. And in order to appreciate this condition, it is only 
necessary to remember that when the blood is in a healthy state, and its 
action upon the brain and whole nervous system is such that the brain 
generates a due amount of vital force or nervous influence, and this influ- 
ence is properly distributed by the nerves to the various organs and 
structures of the body, there is no increase or diminution of nervous 
excitability ; and hence there is no general irritability of the system, and 
there is not likely to be set up any local irritation. 

Let, however, an irritant be introduced into the blood of a stimulating 
character, or let there arise in the mind any violent excitement, as of 
anger, and the brain and whole nervous system may be excited to irri- 
tation ; and this irritation may be slight, or it may be very considerable, 
and attended with a general disturbance of the functions of the body. 
Now I cannot better illustrate this general irritation, than by taking a 
strong man, in a fit of violent anger, with an excited expression of coun- 
tenance, flashing eyes, rapid motions of the body, &c. 

The same condition of general irritation may be produced by any 
irritant introduced into the blood, and if there were no special point in 
the system more predisposed to take on disease than another, this con- 
dition of irritation might be succeeded by a general inflammatory fever ; 
or if the cause were gradually removed, or if it should spend its influence, 
the general irritation might gradually subside, and the nervous action 
might be reduced to its normal state. More generally, however, in 
cases of general irritation of this character, there is some point in the 



52 OF IRRITATION, CONGESTION AND INFLAMMATION. 

system more predisposed than others, in which case there is liable to be 
developed local inflammation ; or in case the cause spends its influence, 
without producing general inflammatory fever or local inflammation, 
there is liable to be left some special point of local irritation. Such local 
irritation may be the result of permanent impressions produced in the 
minute nerves of the extreme arteries, veins, and capillaries ; and 
although it may be permanent, I believe it more generally subsides after 
a time. Such are my views in relation to general irritation, attended 
with increased or augmented nervous action, and such also, I believe, its 
liability to be succeeded by general inflammatory fever, local inflam- 
mation, or permanent local irritation. Let us, then, pass on to consider 
passive or asthenic irritation. 

Passive or Asthenic Irritation. — We have seen that an elevation of 
nervous action above the standard of health, is liable to produce an active 
or sthenic irritation ; we are now to see that a diminished nervous action 
below the standard of health, or nervous depression, will produce general 
irritability of a passive character. This variety of general irritation 
cannot be better illustrated than by a person in great fear, or laboring 
under the influence of protracted grief. The same condition may also 
be produced by various depressing agents introduced into the blood, as, 
for instance, the typhus, contagion, &c. 

Now, whatever may be the depressing agent or influence, vitality is 
depressed, and the brain does not generate sufficient nervous influence, 
and that which is generated is but poorly distributed by the nerves ; in 
consequence of which the circulation is carried on imperfectly, and the 
blood receding from the surface and extreme vessels accumulates in the 
internal organs and parts. The accumulation of blood in the brain, and 
along the pinal cord, may increase the general irritation already pro- 
duced by the nervous depression or diminished nervous action. In such 
cases of general irritation the face becomes pale, the eyes heavy, the 
hand trembles, the mind is irritable, and if the cause continues to operate, 
some kind of general fever, or some local inflammation of a passive 
character is liable to succeed. 

In such cases, if there be no special organ or part more predisposed 
to take on disease than another, the system is liable to rally, if the cause 
is removed, and thus the general irritation may subside. If, however, 
the cause continues to operate, and the agent be some one of the causes 
of fevers, they are very liable to be developed sooner or later. If, how- 
ever, there be some special point in the system more predisposed than 
others, a passive inflammation may be set up, and that, too, with or even 
before the development of general fever. Finally, in cases of general 
asthenic irritation, in which there is produced no general fever or local 
passive inflammation, there is a liability to a permanent general or local 
irritation, caused in most cases by some change in the brain, spinal cord, 
or nervous ganglia. Such, then, according to my observation, is general 
asthenic or passive irritation, and such, also, the liability of its being 
succeeded by some form of fever, passive inflammation, or else of its 
being perpetuated as a general or local irritation, from some permanent 
change in the brain, spinal cord, or nervous ganglia. 

Local Irritation. — We have seen that local irritation may remain in 



IRRITATION. 53 

some organ or structure of the body; the result of general irritation, 
either active or passive, and may become permanent. Local irritation 
may also be produced in any organ or tissue of the body, and too, from 
a great variety of direct causes. Thus we see the eye irritated from 
wind, dust, &c. ; the skin irritated by various acrid substances, the mouth 
and stomach irritated by hot drinks, &c. ; the intestinal mucous membrane 
by crude articles of food, the bladder by cantharides, the brain by want 
of sleep, and in fact there is not an organ or tissue of the body but what 
may be thus accidentally irritated. 

Now in all these cases of local irritation there is evidently a morbid 
excitability of the nerves produced, attended with a sense of heat or 
pain ; and the irritation may pass on to a sufficient disturbance of the 
capillary vessels to develop inflammation or even symptomatic fever, or 
if the cause or causes be removed, the irritation may subside, and the 
part may assume a normal condition; or finally, the irritation may 
remain permanently and yet develop nothing further, being little more 
than an inconvenience, so far as the general healtlys concerned. Finally, 
when we take into account the cerebro-spinal and ganglionic systems of 
nerves, and remember how they connect the different organs of the body, 
we should expect, as we really find, that an irritation of one organ is 
liable to produce sympathetic irritation of another ; and this fact should 
always be born in mind in tracing sympathetic irritations to the primary. 

Nature of Irritation. — It is only necessary to say, under this head, 
that irritation consists in a morbid excitability of the whole nervous 
system or else of the nerves of a particular part ; the nervous action in 
some cases being increased or augmented above the standard of health, 
while in others, the nervous action is diminished or depressed below the 
standard of health ; the irritation probably in all cases being attended 
with a sense of heat, burning or pain. 

Irritation of an active or sthenic character, if it pass on to inflamma- 
tion, develops an inflammation of an active character. If it pass on to 
a general fever, it is liable to be of an inflammatory character. On the 
other hand, if passive or asthenic irritation pass on to a general fever, 
it is liable to be of an intermittent, nervous, or low typhus type ; and 
it* it pass on to local inflammation it is liable to be of a passive character. 

Finally, it is well to bear in mind the fact that all fevers, as well as 
all inflammations are preceded by irritation ; but it must also be remem- 
bered, that all irritations need not necessarily pass on to either fever or 
inflammation, especially if the cause or causes be removed; the irri- 
tation in such cases either terminating by resolution, or else becoming 
permanent, but being only irritations. It should also be remembered 
that irritation is liable to disturb the functions of a part or the whole of 
the body ; depending upon the degree of disturbance in the generation 
and distribution of the nervous influence. 

Causes. — General irritation of the system may be produced, as we 
have already seen, by any exciting or depressing agent, acting directly 
upon the nervous system, or indirectly, by changing the blood. Hence 
we have, as causes of irritation, heat, cold, moisture, electricity, koino- 
miasmata, idio-miasmata, contagions, epidemic and endemic influences, 
&c, as general causes, or as causes of general irritation. We have also 



54 OF IRRITATION, CONGESTION AND INFLAMMATION. 

causes which act locally — as dust or wind to the eyes, injuries of the 
surface from any cause } hot or irritating drinks, coarse articles of food, 
injuries of the brain, or along the spine, &c. It should be remembered, 
however, that the general causes may leave local irritation, or that local 
causes may produce general irritation. 

Treatment. — The treatment of irritation, whether general or local, 
consists in removing the cause as soon as possible, and then in correct- 
ing the morbid disturbance or derangement in the nervous action. If 
the irritation be general, and the cause has been one of excitement, in- 
creasing the nervous action, saline cathartics, cooling drinks, low diet 
and plenty of proper exercise may be sufficient to let down the nervous 
excitability to a normal state. If, however, the irritation be of a pas- 
sive character, the nervous action being depressed below the standard of 
health, then gentle exercise, fresh air, good diet, and if necessary, cam- 
phor, quinine or iron may be required to bring the depressed nervous 
action up to the standard of health. 

In cases of local irritation of an active character, after removing the 
cause, cold applications may be of service. If, however, the local irri- 
tation be of a passive character, warm applications may be required. 

Finally, in cases of sympathetic irritation, depending as it generally 
does upon a primary difficulty in the brain, or along the spine, cups or 
blisters should be applied along the spine, at the seat of the primary 
difficulty, and this being removed, the sympathetic irritation will gene- 
rally subside. 

Now having completed here what I had to say on irritation, we have 
opened the way for the consideration of congestion and inflammation, 
which I shall take up in the two succeeding sections, which will com- 
plete this chapter. The subjects of irritation, congestion and inflamma- 
tion having been thus considered in this chapter, we shall be prepared 
to pass on in the next to the consideration of the pathology, causes and 
phenomena of fevers. 

I make this suggestion here in relation to the course of taking up 
these subjects, in order to keep in mind the importance of each, and to 
call up the important bearing which each one of them has upon the suc- 
ceeding, along our path of general pathology and therapeutics. 

SECTION II.— CONGESTION. 

By congestion is here meant an undue accumulation of blood in the 
extreme arteries, veins or capillaries of any organ or structure of the 
body. The accumulation may take place in the extreme arteries and 
capillaries of a part, in consequence of increased morbid action of the 
heart and arteries, in sthenic conditions of the system, in which case the 
congestion may be called active, especially as it generally follows active 
or sthenic irritation of the part. Or congestion may occur from an 
accumulation of blood in the minute veins of a part as well as of the 
capillaries; the result either of general debility alone, or of debility, 
attended with some local or general obstruction to the passage of blood 
through the veins or right side of the heart, in which case the congestion 
may be called passive, especially as it very often follows asthenic or 



CONGESTION. 55 

passive irritation of the organ or congested part. I will, therefore, pro- 
ceed to consider congestion as active and passive. 

Active Congestion. — By active congestion, then, I mean that which 
occurs in a sthenic condition of the system, and which generally fol- 
lows active irritation ; the accumulation of blood being the result, in 
some cases, of the active irritation, the blood being hurried to the point, 
by the irritation exciting the arteries, and also, more or less, the heart 
itself. Or the congestion may occur in consequence of a general active 
irritation of the nervous system, giving a morbid, excited action to the 
heart ; the active local congestion being produced in consequence of 
some predisposition of the particular part to take an active arterial con- 
gestion. 

When active congestion thus occurs there is a fullness of the part, and 
there is apt to be more or less disturbance in the function of the organ 
or part. If the congestion be slight, there may be an increased or morbid 
activity of function, but if the congestion be considerable, there is a 
liability of a partial or entire suspension of function of the congested 
part ; as we see sometimes in active congestion of the brain, the sus- 
pension of vitality being the result. 

Active congestion may terminate by resolution if the cause be removed, 
or is allowed to spend its force, or the congestion may pass on to active 
inflammation, or a rupture of the blood vessels, and laceration of the 
tissues may occur ; and we may have apolexy, if the congestion be of the 
lungs or brain. It should be born in mind then, that active inflamma- 
tion is always preceded by active congestion of the part ; but that active 
congestion need not necessarily pass on to inflammation, as resolution 
may occur. With this glance at active, let us pass on to the considera- 
tion of passive congestion. 

Passive Congestion. — By passive congestion, as I have already inti- 
mated, I mean that which occurs in asthenic conditions of the system ; 
the accumulation taking place in the capillaries and extreme veins, and 
depending upon debility with or without some special obstruction to a 
free passage of blood through the heart or venous trunks. 

Passive congestion may follow passive irritation, and it may terminate 
by resolution or apolexy, or it may pass on to passive inflammation, as 
most or perhaps all cases of passive inflammation are preceded by passive 
congestion of the part. In cases of passive congestion there is more or 
less fullness of the part with perhaps a feeling of numbness, and if it be 
of the lungs, we have the whole train of symptoms growing out of dis- 
turbed respiration ; or if it be of the brain, of cephalic and general 
nervous depression. 

It is also proper to bear in mind the fact, that we may have congestion 
depending upon local causes, and not necessarily connected with any 
very general disturbance of the system ; the general nervous and circu- 
latory function being in a comparatively normal state. Thus we may 
have cephalic congestion from a continued or even temporary stooping 
attitude. We may also have congestion of the hemorrhoidal veins from 
constipation, or of all the portal veins, from some obstruction to a free 
passage of blood through the liver, &c. 

Congestions then, whether active or passive, or more especially local 



56 OF IRRITATION, CONGESTION AND INFLAMMATION. 

and not attended "with any very marked general exaltation or depression 
of nervous, vascular or vital power, is liable, if the cause be removed, to 
terminate by resolution ; or it may pass on to pulmonary or cephalic 
apoplexy, or if the congestion be active, it may be followed by active, 
or if it be passive, by passive inflammation. With this general view, we 
are prepared to pass on to consider the causes of congestion. 

Causes. — The causes of active congestion are, like those of active irri- 
tation, influences which excite morbid, nervous, and vascular action. 
These causes may act directly upon the nervous system, to excite the 
circulation, as violent anger ; or the cause may act through the blood, to 
irritate, and accelerate nervous and vascular action. It is probable, then, 
that mental excitement, too stimulating articles of food and drinks, and, 
perhaps, a high electrical state of the atmosphere, are among the most 
frequent causes of active congestion. 

Passive congestions, on the other hand, may be produced by a great 
variety of depressing agents, some of which may act directly upon the 
nervous system, as that of fear, melancholy, &c. ; while others may act 
through the blood, as we see illustrated in koino-miasmata, idio-miasmata, 
the contagions, &c. It may also be produced by bad or insufficient food, 
as well as by any and every imprudence which either directly or indi- 
rectly depresses vitality. And besides, as we have already seen, various 
accidental local causes may operate, such as constipation of the bowels, 
positions of the body, ligatures about the limbs, &c. 

Diagnosis. — Active congestion may generally be distinguished from 
inflammation by careful attention to the following differences. In active 
congestion there is slight fullness, a dull, heavy pain, or feeling of numb- 
ness, and but slight, if any elevation of temperature of the part, and 
little or no general heat or special dryness of the skin ; while in active 
inflammation there is pain, tenderness, heat, thirst, swelling, redness, 
and often more or less general febrile excitement. 

Passive congestion may be distinguished from passive inflammation by 
the absence of pain, tenderness, heat, thirst, redness, &c. There is a 
point, however, at which congestions become inflammations, if they pass 
on to that condition, in which it becomes necessary to notice carefully all 
the symptoms, in order to discriminate between them. 

Treatment. — In cases of active congestion, after removing the cause, 
a saline cathartic, cooling drinks, a low diet, &c, may be sufficient to 
overcome the difficulty. If not, however, general or local bleeding, cold 
applications, &c, may be required. In cases of passive congestion, after 
removing the cause, camphor, carbonate of ammonia, wine whey, quinine, 
iron, &c, may be required, and the patient should be allowed a liberal 
diet, good air, moderate exercise, &c. 

Various local applications may be required, depending upon the nature 
and seat of the congestion. If it be of the brain, the warm foot-bath, 
and sinapisms to the feet may be indicated. If the congestion be of the 
lungs or other internal organs, sinapisms may also be of great service. 
Finally, in cases of general congestion, of a passive character, in which 
it becomes necessary to produce reaction at once, in order to prevent a 
suspension of vitality, I know of nothing so effectual as the application 
of a strong infusion of capsicum, in vinegar, along the spine, a little 
warm. 



INFLAMMATION. 57 

It seems hardly necessary to say, that, in cases of congestion depend- 
ing upon local causes, it becomes necessary to remove the cause, in order 
to overcome the difficulty. If the congestion be of the brain, and de- 
pends upon some occupation which requires stooping, the labor should be 
suspended for a time. If the congestion be of the lower limbs, and the 
cause be the wearing of elastics too tight, they should be loosened or 
removed entirely. If the congestion be of the hemorrhoidal veins, and 
constipation be the cause, the use of bread made of unbolted flour, and 
regularity at stool each day, at a particular hour, may overcome the 
constipation. If not, a teaspoonful of sulphur and cream of tartar, of 
each equal parts, may be given each morning, till the constipation and 
hemorrhoidal congestion are overcome. 

Finally, in all cases in which, from any peculiar formation of the body, 
there is a predisposition to congestions, especially of the brain, as is the 
case with persons of large head and short neck, it is important to guard 
against the causes which would be likely to produce it in either of its 
forms. 

SECTION III.— INFLAMMATION. 

By inflammationJ^mejUi that peculiar morbid condition of the tissues 
of the body generally characterized by pain, increased heat, redness and 
swelling ; all of which phenomena, however, are liable to great variation, 
depending upon its character, and also upon the nature of the structure 
in which the inflammation occurs. 

Symptoms or Phenomena. — Redness is the most invariable symptom 
or phenomena of inflammation. It generally occurs in inflamed parts, 
and is owing, in part, to enlargement of the capillaries to such a degree 
that the blood may be seen, while in the ordinary condition of parts the 
blood is scarcely seen in the minute capillaries, or if it is it does not 
appear red, as it does when the capillaries are enlarged. 

It is probable, also, that increased redness may depend, in part, upon 
an increase in the number of red corpuscles in the vessels of the inflamed 
part ; and it may be augmented, in some cases, by extravasation, and 
perhaps by the passage from the arteries to the veins of arterial blood, 
unchanged. 

The redness may vary from a bright red to a deep crimson, or nearly 
purple, and is generally most intense in some one point, and gradually 
diminishes as it recedes, till it terminates in a healthy color. This red- 
ness generally continues after death, and forms one of the evidences of 
internal inflammation in post mortem examinations. Along with the 
redness, there is generally felt by the patient more or less throbbing, 
which is probably owing to an irritation which has been communicated 
to the larger arteries in the immediate vicinity of the inflammation, and 
perhaps augmented by increased density of the inflamed structures. 

Increased heat is another symptom of inflammation, which is sometimes 
absent. It is probable that the sensation of heat, in inflamed parts, de- 
pends on two causes — a slight accumulation of heat, and also an in- 
creased sensibility of the nerves, by which the sensation of heat in the 
part is greatly increased, and hence there is not that elevation of tem- 
perature which the sensation of the part would indicate. 



58 OF IRRITATION, CONGESTION AND INFLAMMATION. 

Yet it is probable that in the first stages of inflammation, the increased 
amount of blood in the part serves to elevate the temperature, especially 
if the inflammation be on the surface of the body, for here the blood is 
constantly receiving oxygen, and throwing off carbonic acid, and most 
likely, in the combustion which occurs in the capillaries heat is evolved, 
as in the lungs, and hence in part its increase. It should be remembered, 
also, that the closure of the exhalent tubes, if the inflammation affects 
the surface of the body, may, by stopping evaporation of perspirable 
matter from the surface, cause to be retained in the part more or less 
heat, which would have passed off in a latent state if the evaporation of 
perspirable matter had continued. 

According to the experiments of Prof. Gross,* the variation in the 
temperature of the blood is from 92° to 104°, the average being 96° ; 
and he also states, that " the temperature of a scrofulous tumor has been 
found raised as much as 5J° above the general heat of the body." 

Pain, though a general, is not an invariable symptom of inflammation. 
As a general rule, the looser the structure inflamed the less violent is the 
sensation of pain. Inflammation of the lungs, or of the alimentary 
mucous membrane, may pass on to even a fatal termination unattended 
with pain. 

The pain arises from an irritation of the nerves of the part ; and that 
irritation may be in part from the cause, direct or remote, of the inflam- 
mation, increased often, more or less, by the swelling of the surrounding 
tissues, and also, probably, by a thickened and tense state cf the neuri- 
lemma. The character of the pain is modified by the nature of the 
inflamed structure. In inflammation of the mucous membranes, if pain 
attends, it is of a burning or stinging character, and not very severe. It 
is important to bear this in mind, as inflammation of the alimentary 
mucous membrane may exist with very little pain, and but slight tender- 
ness to pressure. This slight peculiar pain in the mucous membrane is 
doubtless owing to the looseness of the mucous structures, allowing the 
distention of the small capillaries, without very materially irritating the 
small nerves that surround them, as well as those which supply the capil- 
laries themselves. 

The pain in the pleura, and other serous membranes, is lancinating, 
and generally exceedingly acute. This is doubtless owing to the firmness 
of the serous membranes, so that any enlargement of the small capil- 
laries produces a mechanical irritation of the nerves which intervene 
and surround them, or which enter into their structure. 

Pain in the ligaments or fibrous structures is of a dull, aching or 
gnawing character, owing to the peculiarity of their structure. The 
capillaries are fewer, and probably of a smaller size, than in other tissues, 
in consequence of which their distention does not so materially interfere 
with one another. And further, the firmness of the fibrous structures 
prevents a rapid distention of the capillaries, so that the change which 
takes place is gradual ; hence the gnawing character of the pain which 
is experienced in inflammation of the fibrous structures. 

In inflammation of the cellular tissue the pain is generally not very 
severe at first, but may become so during its latter stages. And this is 
* See Gross' Elements of Pathological Anatomy, pp. 42, 43. 



INFLAMMATION. 59 

as we should suppose, when we remember that the looseness of the cel- 
lular tissue allows the small vessels to be distended without materially 
irritating the small intervening nerves at first. But as the distention 
becomes considerable, and the effused fluid accumulates, the pain is in- 
creased, according to the degree of inflammation, and consequent irrita- 
tion of the nerves of the inflamed part. 

The pain experienced in inflammation of the skin, is of a peculiar, 
smarting, itching or teasing character, just as we should suppose when 
we take into account the peculiar structure of the dermoid tissue. 

For the slightly distended capillaries, pressing upon each other, and 
the intervening nerves, produce a smarting, stinging sensation, while the 
pressure on the exhalent tubes, very likely in part, produces by their 
obstruction, the peculiar itching, teasing sensation. 

This is rendered quite certain, by the fact that such a sensation is 
produced, to some extent, when the exhalents are obstructed by sudden 
exposure to cold. 

The violence of the pain in an inflamed part, controls, to a great extent, 
the sympathetic febrile reaction which the local inflammation produces. 

Thus, in acute bronchitis, or in inflammation of the alimentary mucous 
membrane, the pain is generally not very severe, and there is not a very 
vigorous reaction of the heart and arteries. 

But in inflammation of the pleura, and other serous membranes, in 
which there is intense pain, the arterial reaction is generally very great. 

Sivelling is another symptom of inflammation which varies according 
to the tissue involved, and the degree and extent of the inflammation, 
being generally slight in the mucous membranes, and often very con- 
siderable in the glandular structures. The swelling which occurs imme- 
diately on the occurrence of a local irritation or inflammation, is in con- 
sequence of dilatation of the capillaries ; but if inflammation continues, 
and effusion takes place, the effused serum will of course increase the 
swelling. 

Diagnosis. — Inflammation of external parts may generally be distin- 
guished from irritation, or neuralgia, by the redness, heat and swelling, 
and perhaps tenderness ; some, or all of which symptoms, generally 
attend, rendering the diagnosis clear and decided at once. But to dis- 
tinguish inflammation of internal parts, it becomes necessary to take 
into account the peculiar structure of the suspected tissue or organ, and 
then, by noticing carefully all the symptoms, a correct diagnosis may 
generally be formed. 

By keeping in mind the character of pain peculiar to each tissue, 
inflammation may generally be distinguished from mere irritation or neu- 
ralgia, by keeping in mind the following facts : — In inflammation, the 
pain is generally more continuous, seated and throbbing than in neural- 
gia. In inflammation, there is often tenderness on pressure, which 
symptom is not present in neuralgia, at least to so great an extent. 

Position, too, is often an important diagnostic symptom in internal 
inflammation, the patient generally assuming such a posture as will pro- 
duce the least tension of the inflamed part, while in neuralgia the patient 
is seldom still, appearing more or less relieved by tossing about, and 
getting in almost every position. This we see illustrated in abdominal 



60 OF IRRITATION, CONGESTION AND INFLAMMATION. 

inflammation, as the patient lies on his back, with his knees drawn up, 
in order to take off the tension of the abdominal muscles. 

Inflammation usually produces, also, a general febrile excitement, pro- 
portioned, more or less, to the intensity of the pain ; the pain being 
generally, as we have seen, as the density of the structure inflamed, 
while in neuralgia there is generally little, if any, sympathetic fever 
set up. 

By taking all these peculiarities into account, and also the functional 
derangements which occur, as well as the nature of the exciting cause, 
and by using a good degree of common sense and discrimination, the 
diagnosis between inflammation and neuralgia may be rendered clear, 
and the presence or absence of internal inflammation, in any tissue or 
organ, put beyond a reasonable doubt. 

Causes. — The causes of inflammation are so numerous that an attempt 
at enumeration is quite unnecessary. Any cause capable of producing 
an irritation, such as heat, cold, wounds, morbid poisons, &c, may excite 
local inflammation in any tissue or organ. 

The predisposition to local inflammation, I am satisfied, may depend 
upon directly opposite conditions of the system. In the one case, the 
system being predisposed from a decidedly sthenic, while in the other, 
from an asthenic condition, irritation being the result of both extremes ; 
and hence a predisposition to inflammation; in the one case of an active, 
and in the other of a passive character. 

The predisposing and exciting causes of inflammation should always 
be taken into account, not only in forming a diagnosis, but also in 
arriving at the indications in the treatment ; the indications in the treat- 
ment often being directly opposite in active and passive inflammation. 

Morbid Appearances. — The post-mortem appearances presented in 
cases in which death has been produced by inflammation, varies with the 
tissue involved ; and also with the period or stage of the inflammation at 
which death takes place. 

The most reliable signs of inflammation are an increase of vascularity, 
with more . or less extravasation of blood, or of coagulable lymph, and 
also the formation of pus, or various other morbid products, producing a 
decided change in the structure of the affected part. 

If the patient die during the early stage of the inflammation, there is 
generally found a very minute injection, mainly of the small ramifica- 
tions of the arterial branches, the whole thickness of the tissue being 
filled with dots or strise of a bright red color, and spots of ecchymosis, 
or infiltration of blood, within the texture, and perhaps effusion on the 
surface, may generally be found, as evidence of the inflammation. 

If the inflammation had progressed considerably before death, there 
may often be found an exudation of coagulable lymph, pus, ulcers, &c. 

If, however, the inflammation had become well advanced when deatli 
occurred, there may be found, in many cases, the organization of lymph, 
and its conversion into new tissues; the complete formation of abscesses, 
or of purulent sinuses, adhesions, &c. ; and the minute vascularity and 
redness which appears early, will generally have disappeared. 

By bearing these facts in mind, and taking into account the termina- 
tion peculiar to each tissue, correct conclusions may generally be drawn 



INFLAMMATION. 61 

on post mortem examination ; not only in relation to the existence or 
not, of inflammation; but also as to the stage of the inflammation, at 
which death occurred. 

Nature. — Inflammation is a disease, mainly of the capillary system 
of vessels, consisting in an altered condition of their vitality, and more 
or less sanguineous congestion ; hence, as a general rule, the more abun- 
dant the capillaries of a part, the more liable it is to become inflamed. 

Now, irritation of a part, whether by a wound or otherwise, either 
directly weakens the tone of the nerves of the part, so that the small 
arteries, veins, and capillaries dilate at once, or there is first an in- 
creased tone of the nerves, so that the small vessels at first contract, 
producing a paleness, and then immediately dilate, producing redness. 

This irritation of the nerves of a part, is either direct from the injury 
or else the impression is communicated to the brain, and then, by a re- 
flex action, the nerves of the part become weakened, and congestion 
takes place. 

If the local irritant be slight, and the general system, as well as the 
small vessels of the part are in a sthenic condition, it is probable, that the 
local irritation of the part, first produces contraction, and then dilation 
of the small vessels. But, if the local injury be very considerable, and the 
system as well as the small arteries, veins and capillaries are in an asthenic 
state, it is probable that the nerves of these vessels become stunned as 
it were, and the small vessels are dilated at once, without any previous 
contraction. 

In either case, it is probable that a wound, or injury of a soft part, 
as a blow, either directly or after an instant of irritated action, stuns or 
paralyzes the nerves of the part, in consequence of which, the small 
arteries, veins and capillaries are either immediately or mediately dilated, 
the blood rushing in to distend them, and this constitutes the congestive 
stage of an inflammation. 

The small vessels during this congestive stage of an inflammation, 
may become dilated to two or three times their usual diameter, in conse- 
quence of which, many small capillaries appear which were before invi- 
sible; a result of their admitting red corpuscles, which their calibre did 
not before allow of. 

Now, at the commencement of the congestive stage of an inflammation, 
the current of the blood is more or less slackened, or it may even retro- 
grade for a moment ; but as the dilatation of the vessels becomes com- 
plete, the blood in a sthenic state of the system at least, flows more 
rapidly ; a greater quantity passing in a given time, than in a healthy 
state of the parts. Soon, however, the current becomes again slower, 
especially in an asthenic state of the system ; and there is often com- 
plete stagnation in the centre of the inflamed part, while at the circum- 
ference the blood may pass still with greater velocity than in health. 

The blood thus stagnated is not disposed to coagulate, and the red 
corpuscles accumulate to such an extent, that they not only occupy the 
centre of the current, as in health, but fill up the usual colorless space 
immediately within the walls of the vessels, it being the result evidently 
of a retention of the corpuscles in the dilated vessels, while the liquor 
sanguinis is drained off, and passes along. When the stagnation is com- 



62 OF IRRITATION, CONGESTION AND INFLAMMATION. 

plete and the accumulation of red corpuscles very considerable, their 
outlines may no longer be seen, the vessels presenting a crimson hue. 

During this dilatation of the small vessels, the liquor sanguinis exudes 
more or less through invisible pores, being transparent, unless as some- 
times happens, the coloring liquid of the corpuscles exude more or less 
with it ; but the red corpuscles are not effused unless the orifices of the 
capillaries become ruptured, in which case they may be effused into the 
tissues, and thus give color to the extravasated fluid. 

Soon the fibrin of the extravasated fluid coagulates, and then it 
exhibits organized spherical corpuscles, with numerous interlacing fibrils, 
which give firmness to the mass. These corpuscles resemble those of the 
chyle, and also the white corpuscles of the blood; and "undergo various 
changes, being converted into fibro plastic cells, filaments and possibly 
blood-vessels, when the coagulated fibrin undergoes organization ; and de- 
generating into pus corpuscles, compound granular corpuscles, granules, 
&c, when it becomes quite degraded, to be surrendered ultimately to 
chemical laws."* 

In some cases the corpuscles alone are developed in the exuded liquid, 
on first appearing, in which case, the liquid does not coagulate and is 
incapable of organization. But in cases in which both corpuscles and 
fibrils appear, the coagulated lymph soon becomes organized, red lines 
are seen passing through it in various directions, inosculating and 
ultimately forming blood-vessels, having connection with those of the 
surrounding tissues. In some cases, during the distension of the small 
vessels, the microscope discovers aneurismal pouches of the small arteries, 
veins and capillaries, owing probably to a weakening of their coats, 
caused by the inflammation. 

In parts becoming soft from inflammation, the microscope also renders 
visible granules, and a combination of granular corpuscles cohering in a 
spherical form, and sometimes inclosed by a vesicular envelope. In 
other cases "these corpuscles may be seen apparently in the process of 
disintegration, breaking up more or less completely into irregularly 
clustered and isolated granules, "f And if hemorrhage occurs, large 
corpuscles consisting of several blood corpuscles, surrounded by a trans- 
parent envelope, may be discovered apparently undergoing degeneration. 

Pus, when it is formed, is a yellowish or cream-colored fluid, of the 
consistence of cream and of a sweetish taste, and consists of a serous 
fluid, in which are floating globular corpuscles about twice the size of the 
blood corpuscles, being 3 £^ of an inch in diameter. When the pus 
globules undergo degradation they " are resolved into granules and 
molecules, which ultimately become fluid." Pus also contains, some- 
times, " red blood corpuscles, unchanged exudation corpuscles, com- 
pound granular corpuscles, numerous isolated granules, fatty matter in 
molecules or globules, rhomboidal plates of cholesterin, and the debris of 
the tissues from which the pus proceeds, as cellular fibres, and epithelial 
or epidermic scales. "J 

Theory of Inflammation. — I have already stated that when a cause 
which may produce inflammation acts upon any part, the nerves of that 
part become irritated ; and that this irritation produces either immedi- 

* Wood's Practice of Medicine, vol. i, p. 45. f Ibid. p. 46. J Ibid, p 46. 



INFLAMMATION. 63 

ately or mediately a dilatation of the small arteries, veins and capillaries 
of the part. If contraction first takes place, as it may in a sthenic 
condition of the system, there is at first a paleness of the part caused by 
the blood being in part forced from the small vessels. But if dilatation 
occurs at once, as it is likely to do, in an asthenic state of the system, 
no paleness of the part occurs ; but we have developed redness, heat, 
pain and swelling. 

Now this dilatation may be, in either case, of an active character, but 
it appears to me that it is passive, and the result of the debilitated or 
stunned condition into which the small vessels are thrown by the in- 
truding cause, whatever it may chance to be. However this may be, the 
blood, as it fills these dilated vessels, is interrupted, for a time, in its 
onward course. During this interruption to the onward course of the 
blood, it must necessarily accumulate in the arteries supplying the dis- 
tended vessels, which accumulation may slightly irritate directly the 
arteries, and also indirectly through the cerebro-spinal system acting 
upon the ganglionic nerves. As a consequence of this irritation, direct 
and indirect, the blood is again sent on through the distended vessels 
with more or less of an accelerated movement, and as nutrition or depo- 
sition of fibrin is suspended in the part, it necessarily accumulates, to 
some extent, in the blood. This accumulation of fibrin probably causes 
the corpuscles to cohere, rendering the blood more viscid, in consequence 
of which, the red corpuscles accumulate in the dilated vessels, thus filling 
up their increased capacity. In consequence of this clogging of the ex- 
panded vessels by the blood corpuscles, the onward movement of the 
blood is again impeded, and, finally, becomes stagnated in the central 
portion of the inflamed part, an increased quantity of blood, however, 
being sent through the vessels towards the circumference of the inflamed 
part, where the vessels are less clogged if the system is in a sthenic con- 
dition ; but if the system is in an asthenic state I think it is doubtful. 

Thus we have, in my view, the rationale of inflammation fully estab- 
lished, consisting essentially in irritation, debility, and a general de- 
ranged condition of the inflamed part, and a more or less irritated con- 
dition of the heart and arteries, with either an increased or diminished 
power of action, constituting active or passive inflammation, according 
as the system is in a sthenic or asthenic state. 

Terminations. — Inflammation having been thus fully established, tends 
to a termination. There is, however, at this stage, an effusion of serum 
and lymph, and, perhaps, of blood, which, if the inflammation terminate 
by resolution, are absorbed, and the part passes on to a healthy state. 

If, however, the inflammation continues, the effused fibrin may coagu- 
late, its invisible germs taking the shape of molecules, which unite in 
rows, forming fibrils, or about a centre, forming granules, and which 
ultimately develop exudation corpuscles. These fibrils, by uniting, form 
tissues, while the corpuscles, which become nucleated cells, may undergo 
various changes, probably elongating and joining end to end in some 
cases, they form the basis of fibrous tissue, and, perhaps, of blood vessels. 
But if neither resolution or the organization of the effused fibrin takes 
place, various degrees of destructive processes may occur, the most fre- 
quent of which are suppuration, ulceration, softening, and gangrene, 
each of which are entitled to a passing notice. 



64 OF IRRITATION, CONGESTION AND INFLAMMATION. 

Suppuration may take place in any protracted case of inflammation, 
especially if from a poverty of the blood, the exuded lymph is of a de- 
fective quality. In such cases, the exudation corpuscles lose their vitality, 
and become pus-corpuscles, and the other ingredients of the coagulated 
exuded matter, becoming liquid, are converted into granules of pus. And 
if the pus be not soon evacuated from its cavity in the tissues, its cor- 
puscles may become granules, and these granules, finally, assume a liquid 
form, which renders it liable to be absorbed. 

The tendency to suppuration in an inflammation is supposed to be 
strongest in cases in which the exuded matter contains the greatest quan- 
tity of exudation corpuscles, and the least of the fibrillating material, 
the fibrils tending, as we have already seen, to coagulation and organiza- 
tion, while the exudation corpuscles, if in excess, tend to pass on to pus- 
corpuscles. 

Ulceration is liable to occur from inflammation in constitutions in 
which there is a deficiency of vital force, and appears to be the resolu- 
tion of the tissues into u compound granular corpuscles; or isolated 
granules, and the ultimate liquefaction of these products, so that they 
may be absorbed when not eliminated with the pus."* 

Softening is another effect of inflammation, and, according to Professor 
Gross, most frequently occurs in " the brain, the spinal cord, the mucous 
membrane of the alimentary tube, the spleen, and liver." According to 
my observation, softening as frequently follows a slow or chronic inflam- 
mation, and it appears to be the interstitial cellular tissue of structures, 
which are mainly at fault, in most cases, at least. 

The effused lymph appears to undergo degeneration, and, at the same 
time, the tissues themselves ; the result or product being granules, either 
diffused or in mass, and "the debris of the softened organs. "f 

Gangrene, mortification or death of a part, is liable to occur as the 
result of inflammation, and it is the lowest degree of degradation to 
which the tissues are liable. It may be a slow or rapid process, varying 
from a few hours to several months, from the beginning of the inflam- 
mation which produces it. When it is about to occur, the temperature 
of the part as well as its sensibility is lost, and very soon the circulation 
becomes suspended, and all its other functions. 

The textures most liable to gangrene are the mucous, cellular and 
cutaneous ; while those parts in which it seldom or never occurs, accord- 
ing to Prof. Gross, are " the uterus, kidneys, ovaries, supra-renal cap- 
sules, the thyroid body, the testicles, paucreas, and salivary glands." 

Thus we have traced inflammation through its various processes of re- 
solution, the formation of new tissues and its various destructive termi- 
nations. Let us now look at its modifications, depending upon the 
tissues in which it occurs. 

Modifications of Inflammation. — Inflammation may be said to occur 
under five prominent modifications, corresponding to the five elementary 
tissues ; the cellular, serous, mucous, dermoid, and fibrous. 

Inflammation of the cellular tissue is characterized by great swelling, 
throbbing pain, and by the puculiarity of the pus being collected in 
circumscribed cavities. 

* Wood's Practice of Medicine, vol. i., p. 49. 

f See Gross' Elements of Pathological Anatomy, p. 8S. 



INFLAMMATION. 65 

Inflammation of the serous structures is distinguished by acute lanci- 
nating pain; little or no swelling, sympathetic reaction of the heart and 
arteries, by its tendency to terminate in the exudation of coagulable 
lymph or the secretion of a thin whey-like pus. 

It is rapid in its course, and not apt to terminate in gangrene, and is 
peculiarly liable to form adhesions. 

Inflammation of the mucous tissue is attended with a stinging burning 
pain, as we have seen, without much tumefaction of the subjacent cellu- 
lar structure ; the sympathetic fever which it develops is not vehement, 
and when it terminates in resolution there is an increase of the mucous 
secretion. 

Inflammation of the skin, or dermoid structure is attended with a 
burning pain ; is much inclined to spread over the surface, forming small 
blisters, containing serum, and never forms adhesions, or suppurates in 
circumscribed cavities. 

Inflammation of the fibrous structures is attended with intense aching 
or gnawing pain, and is not disposed to terminate in suppuration or gan- 
grene ; it may however, terminate in the exudation of serum, or in the 
deposition of earthy matter. It is peculiarly liable to change its loca- 
tion from one part to another, and sometimes passes suddenly to internal 
organs. The sympathetic fever which accompanies acute rheumatism, 
is generally vigorous ; but it seldom proves fatal, unless it passes to 
some internal part, or organ essential to life. 

Though the preceding modifications may not always appear exactly 
as I have pointed them out, I am confident that the careful observer 
will find those peculiarities to be the prevailing tendency. 

Varieties of Inflammation. — Inflammation may be either acute or 
chronic, active or passive. Acute inflammation is rapid in its course, 
and violent in its local and symptomatic phenomena. Chronic inflam- 
mation is generally the result of the acute ; and is characterized by a 
slow progress, and less intensity in all its symptoms. 

By active inflammation I mean one occurring in a sthenic constitution, 
and though there be irritation with debility at first, at the seat of the 
inflammation, and soon an irritated condition of the heart and arteries ; 
when the local inflammation is established and the circulatory system 
excited, there is with the irritability an increased power of action. 

By passive inflammation, I mean one occurring in an asthenic or de- 
bilitated constitution, in which the debility is a predisposing cause : and 
though there may be irritation at the point of inflammation, of the small 
dilated vessels, and also of the circulatory system generally, yet in both 
there is a diminished power of action. 

Treatment of Inflammation. — I do not propose here, to do more than 
to point out the general indications in the treatment of inflammation, 
which may serve us as we proceed in our investigation of inflammatory 
diseases, of the different tissues and organs of the body. 

If we take into account the great fact, that a medium action of the 
circulatory system, not only of the heart and arteries, but also of the 
capillary vessels is desirable in order to promote resolution of an inflam- 
mation, we have reached the great indication in the general and local 
treatment of all inflammatory affections. For if an inflammation occur 



GQ OF IRRITATION, CONGESTION AND INFLAMMATION. 

in a sthenic or strong and vigorous constitution, and the local and gene- 
ral irritation of the capillary and general circulatory system when the 
inflammation is fully established, is attended with increased power 
of action of the heart and arteries, as well as the capillaries of the in- 
flamed part, the action of the circulatory system both general and local 
may be too strong, and therefore require to be reduced to a medium 
standard. 

In such cases, the deviation from a medium standard should be taken 
and the general and local action reduced by the most safe, convenient 
and reliable measures. 

If the arterial action be very strong, general and local bleeding may 
be indicated, with antimony, veratrum, digitalis, &c. ; and cold applica- 
tions to the inflamed parts till the excitement of the circulatory system 
is reduced to a medium standard. But if the increased action of the 
circulatory system be not so high above a medium, the warm foot bath, 
warm sage tea, and perhaps a saline cathartic with small doses of ipecac 
may be sufficient to bring the circulation down to a medium action. 

Thus we have clear indications in all cases of inflammation in which 
there is increased arterial and capillary action. Let us now inquire 
into the indications in cases of inflammation occurring in asthenic or 
debilitated constitutions. 

In cases of inflammation occurring in asthenic or debilitated consti- 
tutions, there may be, along with the local and general irritated state of 
the circulatory system, a diminished power of action, not only of the 
capillary vessels, but also of the heart and arteries, in consequence of 
which the general and local action of the circulatory system will fall 
below the medium, and so an indication for tonics, and stimulating appli- 
cations to the local inflammation may clearly exist. In such cases, to 
bring up the general circulation, as well as the capillary, to a medium 
standard, and thus favor resolution, quinine, camphor, and perhaps diffu- 
sible stimulants may become necessary, as well as warm or stimulating 
applications to the inflamed part. Thus we have the great principles to 
guide us in the treatment of all inflammatory affections. 

In relation to the special indications which are liable to arise in in- 
flammation of different organs and structures of the body, it is more 
proper to leave them to be considered as we take up inflammations of 
these tissues and organs in their proper place. Enough has, however, 
been said here to enable us to pass on with our subjects, in the order in 
which I have already announced them. 

I trust that, having thus considered irritation, and having traced it to 
its terminations by resolution, and also to congestion, and having consi- 
dered congestion, with its terminations, one of which is in inflammation, 
and finally, having taken up inflammation, that we shall be well prepared 
to pass on, in the next chapter, to a consideration of the pathology, 
causes and phenomena of fevers, alter which we may pass smoothly along 
through our investigations of the general and local diseases to which the 
human system is unfortunately liable. 



CHAPTER III. 
OF FEVER. 



SECTION I.— THE PATHOLOGY OF FEVER. 

Fever is the direct or remote effect of some irritant or morbific agent, 
applied to or acting upon the fluids or solid tissues of the body. What- 
ever may have been said of the nature, causes, and symptoms of fever, 
there can be no reasonable doubt but that irritation is the immediate 
cause of the symptoms which are developed in febrile affections. 

A morbific agent may act on the system for some time before the 
system becomes highly irritated and fever developed. Hence it is, that 
in most fevers there is a forming stage of debility, in which the morbific 
agent is producing through the blood, or otherwise, a debilitating effect 
upon the brain and whole nervous system. We find this debilitating 
agent, whatever it may be, prostrating the strength, confusing the opera- 4 
tions of mind, weakening the strength and force of the heart and arte- 
ries, deranging the secretion of the liver, kidneys, and glandular system 
generally, impairing the appetite, constipating the bowels, and rendering 
irritable the nervous system. 

Now, a morbific agent which is capable of producing fever, may pro- 
duce confusion of the mind by its debilitating or irritating effects upon 
the brain. If, then, a morbific agent has entered the blood, it soon 
reaches in its course the brain, and by there producing its peculiar effects, 
so far deranges that organ as to interfere with the natural development 
of mind, as we find in the forming stages of most fevers. If that agent 
be a narcotic, it diminishes action, and renders the circulation through 
the brain sluggish and tedious, as is the case in most of our miasmatic 
fevers. Hence the almost universal statement of patients, during the 
forming stage of fevers, that they feel stupid and sleepy, and have little 
ambition to do anything. If the morbific agent has been a stimulant, 
the brain may have been irritated directly, and the circulation through 
its vessels accelerated for a time. In this case the patient will complain 
of great irritability, and yet feel weak and prostrated in body and mind. 

The debility which almost invariably prevails in the forming stage of 
fevers, is probably first brought about by the direct action of the morbific 
agent upon the brain and whole nervous system. And when we take 
into account the fact that the brain and all the nervous system are the 
immediate agents by which the different organs derive their ability to 
act, we shall readily see how the different organs in their turn become 
involved. By careful observation we find that this disturbed condition 
of the brain and nervous system is felt immediately by the stomach, 
probably through the pneumogastric and sympathetic nerves. The 



68 OF FEVER. 

appetite becomes indifferent, and by degrees is destroyed. The taste 
of the mouth becomes changed and unnatural, nausea and a loathing of 
food follows, and this cutting off of the supply of food or nourishment 
goes to increase the prostration. 

The liver, the function of which depends upon a due supply of nervous 
influence, is either rendered torpid or else is called into increased action, 
according to the nature of the morbific agent. If its secretion be les- 
sened, the want of bile to mix with the food which is taken, aids in im- 
pairing the appetite, and also produces constipation of the bowels. If 
its secretion be increased by the influence of the morbific agent on the 
brain, we have an undue amount of bile thrown into the alimentary 
canal, which may, and generally does, produce a diarrhoea or a morbid 
condition of the mucous membrane of the stomach and intestines, and 
this goes still further to impair the appetite and increase the prostration 
and general debility. 

The kidneys, too, are soon involved in this sympathetic derangement, 
and we generally find them either in a morbidly active state, secreting 
an undue amount of urine, or they become inactive, secreting very little ; 
in either case their derangement goes to increase the morbid condition 
of the system. For if they secrete too much, they, by robbing the blood 
of its fluid parts, derange the circulation, and increase the derangement 
of the various organs, already too much impaired. But if, as generally 
happens, their secretion be lessened, we have retained in the blood 
another morbific agent, which, in its turn, acts upon the already de- 
ranged brain and nervous system. In fact, so important is this excre- 
tion to the well-being of the system, that even life cannot long continue 
without it ; for the urine retained in the blood not only irritates the 
brain, but poisons, in a greater or less degree, every tissue to which it is 
carried. And it is very likely that the retained urine, passing through 
the blood-vessels, capillaries and tissues, produces an irritability, which 
is carried through their nerves to the brain, and serves, very materially, 
to derange its function ; and that derangement, in turn, being reflected 
to the various organs, increases the general derangement. 

The shin, too, is more or less under the influence of the cerebro-spinal 
and nervous system ; and as all this derangement renders the system 
either languid or irritable, we find the skin either passively exhaling too 
much of the fluid parts of the blood; or, as is more common, with 
diminished action, retaining too much. 

Now, if the skin is throwing off too much, as we find it in some con- 
ditions of prostration, in the forming stage of fevers, the blood, in con- 
sequence, is rendered thick, having too little of the watery parts, and as 
a consequence, the strength of the system is often rapidly impaired, and 
in the same ratio its various functions become deranged. 

But if, as is more common in the forming stage of fevers, the skin 
becomes torpid, throwing off too little, we have a poison retained in the 
blood, which going to the brain, increases the morbid condition, and also 
very likely irritates the heart, arteries, capillaries and veins, or their 
extreme nerves, and this irritation is sent through their nerves, to the 
great nervous centre, from which it is reflected to the various organs, 
the functions of which become still more impaired or deranged. Thus it is 



THE PATHOLOGY OF FEVER. 69 

that irritating or morbific agents, entering the blood, act upon the brain 
and the whole nervous system, by either directly debilitating or irritating, 
and then by direct and reflex action they derange the whole system, in 
a greater or less degree impairing the functions of its various organs. 
"While it is the direct action of the morbific agent upon the brain which 
is the cause of the deranged condition which exists during the forming 
stage of fevers, it is probable, as we have seen, that a part of this influ- 
ence is carried from the extreme nerves, which supply the inner coats of 
the arteries, veins, lymphatics and capillaries, to the nervous centre. 

Now, the forming stage of fevers is characterized, as we have seen, by 
debility, which debility and prostration may, and generally does con- 
tinue for several days ; till, though irritable, the system sinks down, 
the brain and whole nervous system appearing no longer able, by their in- 
fluence, to carry on the functions of the body: the heart and arteries 
feel the influence ; the blood recedes from the surface of the body and the 
extreme vessels ; congestion of the brain and spinal cord is the conse- 
quence ; and as the nervous system is impaired, and the circulation 
sluggish, too little oxygen is received into the blood, by the skin and 
lungs, to unite with the carbon and keep up animal heat, and there 
comes a chill. During this chill, or cold stage, the whole system is in 
an inactive or torpid state, but the brain, probably from undue pressure 
upon its substance, begins to grow irritable, which irritability increases 
till it sends forth an influence that compels the heart to renew its activity, 
and thus reaction is set up. 

Now, this command of the brain to the heart and arteries, is carried, 
I apprehend, through the sympathetic nerve directly to the heart, and 
through the sympathetic and cerebrospinal nerves to every part of the 
system. And with such power and energy is this command obeyed, that 
the whole system is brought into a state of excitement. The heart con- 
tracts powerfully ; the pulse beats actively ; the blood flows through the 
heart, arteries, capillaries and veins rapidly, and as a consequence, im- 
mense quantities of oxygen are received into the blood by the lungs and 
capillaries of the skin ; animal heat is revived, and generally accumu- 
lates to such a degree, that there is a hot skin, dry tongue, and a general 
feeling of oppressive heat. 

This preternatural heat and general excitement continues for a time, 
and then the heart and arteries, as if exhausted by over action, generally 
abate their action, and resume their accustomed activity. Or, what is 
more common, they sink below their accustomed activity, if no local in- 
flammation has taken place during the excitement. The various func- 
tions of the body are restored, or approximate more nearly their normal 
state. And if no local inflammation is set up the skin usually becomes 
moist, for a time, and the urine free. 

Now I have made this increased action of the heart and arteries to 
depend upon the excitement of the brain and nervous system directly, 
and such I believe to be the case in the main ; but no doubt, the morbific 
or irritating agent in the blood, may, and does operate to a certain 
degree, directly upon the extreme nerves of these vessels. And it is 
probable, that the morbific agent in the blood, directly irritates the 
different organs as it passes through them, and thus, in part, deranges 



70 OF FEVER. 

their functions ; but it must be remembered, that if it does, its impres- 
sion can probably be received only by their nerves, which impression 
is conveyed by them directly to the brain. 

But as the blood cannot be supposed to pass out of the vessels, it is 
more than probable, that any direct influence of that kind must act upon 
the extreme nerves, which terminate on the inner surface of the heart, 
arteries, capillaries and veins. But how far such an influence may go 
to produce the debility of the forming stage of fever, is not quite certain. 
I apprehend that the brain receives every impression of that kind imme- 
diately, and then transmits the morbid influence to the various tissues 
and organs, as I have before suggested. 

Thus far w T e have only considered the action of causes on the system 
through the blood, and producing their effect directly upon the brain and 
nervous system. Fevers thus produced without any local inflamma- 
tion, acting as a cause, have been called idiopathic. That such fevers 
occur, there can be no reasonable doubt, for we see them continuing for 
days, weeks and months, without any local inflammation being developed, 
at least, so far as we can discover. Such fevers generally have very re- 
marked remisssions or intermissions, if no local inflammation is set up. 
But if, as generally happens, a local inflammation is set up in some tissue 
or organ, that local inflammation becomes a constant source of irritation 
to the brain and the fever becomes more continued. 

The frequency of local inflammation occurring in idiopathic fever, is 
the probable reason why so many have doubted even their ever occur- 
ring ; and so have regarded all fevers, as the result of local inflammation 
in some tissue or organ. But when we take into account the various 
contagious fevers, as well as pure intermittent fever, we cannot reason- 
ably doubt their ever occurring. — But in what way is the poison intro- 
duced into the blood to produce idiopathic fevers ? It is probable that 
the lungs is the most frequent medium through which morbific agents are 
received into the blood, as it is the most direct. 

The air is constantly charged, in some localities, with poisons in a 
greater or less degree. And as the oxygen of the air enters the blood, 
it is fair to infer, that the noxious agents which the air contains, may, 
and do enter the blood. For there is only a thin membrane which 
separates the current of blood in the lungs from the air we breathe ; and 
that membrane expressly adapted to transmitting air. Now if this 
membrane can take in oxygen and pass out carbonic acid, it can also 
transmit the noxious gaseous agents which the air contains, and that 
too, without necessarily producing directly an inflammation of that 
membrane. And the length of time that certain morbific agents are 
known to remain in the blood before they develop fever, is sufficient 
evidence that what we call idiopathic fevers, cannot be located in the 
lining membrane of the lesser air tubes and cells of the lungs, which, in 
fact, would render them symptomatic. 

The stomach is probably also a medium through which these poisons 
may be introduced into the blood. For as the air passes freely through 
the mouth, its noxious principles may become involved in the saliva, and 
so pass into the stomach and blood, and become the cause of general 
fever, without necessarily producing inflammation of the mucous mem- 
brane of the stomach and intestines. 



THE PATHOLOGY OF FEVER. 71 

Certain articles of food may contain poisonous principles, which are 
frequently taken into the blood through the stomach, and gradually 
develop general fever, without first having produced any local inflamma- 
tion. Various articles of drink also contain poisons which may go with 
the fluid through the absorbents into the blood, and passing to the brain, 
sooner or later develop fever without producing first local inflammation. 

The skin too, is a medium by which agents may be received into the 
blood, and go to develop general fever without at first necessarily infla- 
ming the skin. 

This absorption of the skin may be from the air, as it is probable that 
oxygen is constantly entering the capillaries, and carbonic acid being 
thrown off, as in the lungs ; or, the lymphatics of the skin may absorb 
gaseous or liquid poisons and carry them into the blood. 

Thus we have seen, that there are various ways in which morbific 
agents may be introduced into the blood ; and that once in the blood, 
they may, and do produce general fever without first having produced 
local inflammation. Let us see now whether these morbific agents pass as 
foreign substances in the blood, or whether by changing or dissolving the 
blood they render the blood itself an irritant. 

It is possible that the paludal poison which produces ague, may affect 
directly the blood-corpuscles, but I incline to the opinion, that the symp- 
toms in our paludal fevers which appear to indicate that change is the 
result of impaired digestion, and temporary derangement of the liver, 
where it is probable that the blood cells receive their iron. Now, if it be 
a fact, that the blood-corpuscles are fewer in the blood, after a protrac- 
ted ague, than in a state of health, I think it is reasonable to infer, that 
the deficiency may be owing to imperfect digestion, in consequence of 
which, suitable materials are not furnished for their formation in the 
mesenteric glands, and especially that they may fail to receive in the 
liver their due supply of iron ; this to me appears the more rational solu- 
tion of the fact, than to suppose that the blood-cells are dissolved direct- 
ly by the paludal poison. This appears the more probable when we 
remember that during the early stages of intermittent fever, the various 
functions are frequently performed with a degree of regularity that could 
hardly be expected if the blood-corpuscles had been directly dissolved 
by the paludal poison. 

It is probable then, that the paludal poison which produces our mild 
intermittent and remittent fevers, may and does pass along with the 
blood, in something the same way that oil may be mingled with water 
without a chemical union or decomposition of either : on the other hand, 
those morbid poisons which produce malignant fevers of a contagious 
character, as for instance, the morbid poison of typhus, may, and pro- 
bably do unite chemically with the blood, and so far decompose or change 
it, as to render it unfit to stimulate the brain in a proper manner, sc 
that the various functions of the system are permanently impaired, and 
consequently no remissions or intermissions occur. 

The purpurea which occurs in some malignant fevers, as well as the 
passive hemorrhages, go to confirm the idea of a decomposed or changed 
state of the blood ; this I conceive to be an important difference between 
the morbid contagious poison of typhus, and the morbific agent which 



72 OF FEVER. 

produces our paludal fevers, and the reason why, in the one class we have 
intermissions, or marked remissions, while in the other the fever is 
continued, generally from the first. 

Now, as we have seen, it is probable that purely idiopathic fevers may 
and do occur, and sometimes pass through a regular course ; but it is 
likely that very many cases, which are so considered, are really symp- 
tomatic of local inflammation in some tissue or organ which has been 
overlooked. At any rate, local inflammation is frequently set up in some 
tissue or organ, which very materially modifies the course, type, symp- 
toms, and danger of fevers. 

We must remember that the stomach and intestines sympathize very 
strongly with the brain, and depend entirely upon the brain for the 
power to perform their function. And this sympathy is, probably, first 
through the pneumo-gastric and sympathetic nerves. But we have seen 
that the circulation through the different organs becomes deranged; and 
as the blood, too, is not in a natural or healthy state, it is probable that 
the stomach is unable to secrete from the blood the acetic and hydro- 
chloric acids, and also its nitrogenous principle, for the digestion of what 
food is taken. In consequence of this, crude articles of food are passed 
through the alimentary canal in an undigested state, which, acting upon 
the mucous membrane of the stomach and intestines, sets up an irrita- 
tion, and we soon have gastro-enteritis, which very much modifies the 
character of the fever. 

And so soon is this inflammation produced, that in many cases it ap- 
pears to even precede, when it is really a consequence of the general 
fever. 

I am satisfied, from careful observation, that, in many cases, a gastro- 
enteritis is thus produced, even before the fever is fully established, and 
becomes so complicated with the first stages of the fever, as to make it 
even a matter of doubt, which is the cause and which is the effect of the 
fever. 

The liver, too, as we have seen, soon becomes involved in general fever, 
and either its secretion is materially diminished, or morbidly increased ; 
in either case the effect becomes a source of irritation to the alimentary 
mucous membrane. If its secretion is diminished, there may not be suf- 
ficient bile to unite with the nutritious part of the food which is digested 
by the stomach ; and, in this case, chyle is not formed, or, if it is, it is 
of an imperfect character, and does, probably, very little towards sup- 
porting the decaying strength. 

But this deficiency of bile also produces constipation of the bowels, 
and thus another source of irritation is brought to bear in producing 
gastro-enteritis. And so if too much bile is secreted, as happens in 
some cases of fever, the excessive secretion poured into the intestines, 
produces, as we frequently see, a bilious diarrhoea, and serves, in a greater 
or less degree, to irritate or inflame the alimentary mucous membrane. 
Again, the secretion of the liver in the forming stage of general fevers, 
is probably of an unhealthy character, and though the quantity may 
be neither too great or too small, yet, being of an acrid character, in 
consequence of the deranged condition of the organ, when it is poured 
into the intestines it serves as a direct irritant in producing gastro-en- 
teritis. 



THE PATHOLOGY OF FEVER. 73 

Now, as the liver is one of the first organs that becomes involved in 
the derangement of the system, in the forming stage of fevers, it is pro- 
bable that it is an important agent in setting up or producing, in the 
ways I have suggested, gastro-enteritis. And so insidious is this cause 
in its action, that no wonder that wise men have supposed that the 
gastro-enteritis was the primary cause of the fever, and that all fevers 
are essentially symptomatic of local inflammation. I have known many 
cases of general fever in which, without the most careful inquiry in 
reference to the early symptoms, I should unhesitatingly have pro- 
nounced the fever the consequence, and not the cause of the local disease. 
Now the causes thus operating so early to produce gastro-enteritis, having 
once produced the local inflammation of the alimentary mucous mem- 
brane, have also furnished another source of irritation to the brain, which 
sympathetic irritation of the brain modifies very materially the incipient 
fever, and produces a variety of complications which otherwise might not 
exist. 

The kidneys, too, as we have seen, become involved in the forming 
stage of idiopathic fevers. And their morbid action, whether it be to 
secrete too little or too much, has an important bearing upon the 
mucous membrane of the stomach and intestines, as well as on the brain 
and nervous system directly. For if they secrete too much from the 
blood, it robs the mucous membrane of a due amount of moisture, and 
thus increases indigestion, constipation, irritation, and inflammation of 
the alimentary mucous membrane, and that, too, at an early stage of the 
fever. But if, as generally happens, the kidneys secrete too little, the 
mucous membrane of the stomach and intestines become congested with 
too much watery blood, and irritation and diarrhoea is frequently the 
result, even in the first stages of the fever. Again, as we have seen 
that the parts of the fluid retained in the blood, in consequence of inac- 
tivity of the kidneys, are of an irritating character, it is more than pro- 
bable that, by entering the capillaries of the alimentary mucous mem- 
brane, it directly irritates that membrane, and thus produces gastro-en- 
teritis in the forming or any subsequent stage of fevers. 

We have seen, too, that in general fever the skin soon becomes in- 
volved, either throwing off too much or too little ; and this, too, becomes 
another source of irritation to the mucous membrane. 

And that the functions of the skin should become deranged is not 
strange, when we remember that it depends entirely upon the brain and 
whole nervous system for the ability to perform its functions in a proper 
manner. Now if the skin exhale too much of the fluid parts of the 
blood, it has an effect similar to that produced by a too copious secretion 
of urine, both generally, and upon the alimentary mucous membrane. 

But if, as generally happens, the skin becomes inactive and torpid, 
and fails to throw off its accustomed secretion, by far more serious con- 
sequences follow. For the alimentary mucous membrane, being only a 
continuation of the skin, sympathizes very strongly with its derange- 
ment, and, unless a vicarious discharge is set up by the kidneys, is sure 
to become congested, and thus irritated and inflamed in a greater or less 
degree. But if, as generally happens, both the kidneys and the skin 
are in a torpid state, congestion of the alimentary mucous membrane is 



<4 ; 0F FEVER. 

the inevitable result, and that, too, in a very early stage of the general 
fever. Now this congestion cannot long continue without developing 
irritation and inflammation. 

But the mucous membrane sometimes makes an effort to relieve itself, 
by pouring out this fluid into the intestines. Hence the diarrhoea which 
occurs in the early stages of some fevers, and which may then be re- 
garded as a favorable indication, if it be the result only of congestion. But 
the gastro-enteritis which is set up by the various derangements which I 
have enumerated, is the cause of that species of diarrhoea which occurs 
in the latter stages of fatal cases of idiopathic fevers. 

I have been thus particular in expressing my views in relation to the 
manner in which general fevers may originate in the system, without a 
previous local inflammation. It is a conclusion which I am compelled to 
arrive at, after a careful observation of a great variety of cases, during 
the past twenty years. I have also attempted to show how general 
fever, by deranging the functions of the various organs, may develop, 
at an early stage of idiopathic fevers, an inflammation of the alimen- 
tary mucous membrane, which inflammation modifies very essentially 
almost every stage of general fever, and becomes a fearful source of 
fatality, when this local affection is neglected. 

And now, if I have established the fact, that idiopathic fevers may 
occur, and the manner of their development, as well as the great liability 
of subsequent derangement and inflammation of the different tissues and 
organs, but especially of the alimentary mucous membrane, I have accom- 
plished the end at which I aimed. And now, having thus laid down the 
most essential principles involved in the pathology of idiopathic fevers, 
let us examine with patience the principles involved in the pathology of 
symptomatic fever ; and though some of these principles have been 
already anticipated, calling them up in this connection may be the means 
of fixing them more permanently in the mind of the student, at least. 

Symptomatic Fever. — A symptomatic fever is one which is produced 
by a local irritation or inflammation in some tissue or organ, without 
any previous general fever. And in this connection, it may be proper 
to state that there is not a tissue or organ in which irritation or inflam- 
mation may not develop or produce general fever ; and though it will 
be impossible for us to examine all the local inflammations, in order to 
see how they produce fever, we will examine enough to illustrate the 
principle at least. 

Inflammation of the shin produces general fever. We see this illus- 
trated in scalds or burns, which inflame the skin, and the degree of the 
general fever appears to depend very much upon the extent of the sur- 
face involved in the inflammation. If the space, or part of the skin 
involved in the inflammation be small, the fever which is set up is slight, 
and the constitutional derangement not very great. But if the surface 
of skin which is involved in the inflammation is great, we have a high 
fever, and very general derangement of the system, and especially of 
the brain and whole nervous system. 

Now, a scald or burn, embracing a large extent of skin, irritates the 
extreme nerves of the skin, and this irritation is carried by them to the 
brain and spinal cord, and instead of at once developing fever, the brain 



THE PATHOLOGY OF FEVER. 75 

appears to be debilitated by it, and great prostration comes on and con- 
tinues for a time. The skin involved becomes red, hot and inflamed, 
while the general system appears by this local inflammation to be ren- 
dered debilitated, inactive and prostrated. The heart and arteries appear 
for a time to have lost their accustomed vigor. The circulation becomes 
sluggish, and in consequence, too little oxygen is received into the blood 
to unite with its carbon. There is a letting down of vital heat, and fre- 
quently a chill more or less severe follows. The brain and spinal cord 
become congested during the chill, and more or less irritated, and they 
finally send forth an influence to the heart and arteries which provoke 
their renewed activity. The blood which had receded from the extreme 
vessels, and had compressed unduly the vital parts, is sent to the ex- 
tremities, and into the minute capillaries, which were before contracted. 
The pulse becomes firm, strong and rapid ; the respiration is accelerated ; 
the amount of oxygen consumed is greatly increased ; animal heat accu- 
mulates, and a general feeling of oppressive heat, irritability and excite- 
ment follows, and thus we have a general fever established from a local 
inflammation. This state of febrile excitement may be continued during 
the whole period of the local inflammation. But generally, after a longer 
or shorter period, the febrile excitement abates, and the various organs 
resume their functions as the local inflammation subsides. 

The brain and whole nervous system appear to suffer materially in such 
cases. Indeed, in no other variety of fever have I ever witnessed such 
excessive irritability of temper and excitement of the nervous system. 
This is, doubtless, owing to various causes, not the least of which is the im- 
mense number of nerves, the extreme points of which are involved in the 
local inflammation ; they taking the irritation to the brain and spinal 
cord, and thus producing the general irritability which follows. Another 
cause of the excessive irritability may be found in the loss of serum 
which occurs in such cases, and also in the change which takes place in 
the skin, as well as the various organs of the body. 

But by far the greatest source of the nervous irritability in such fevers, 
I apprehend to be in the sympathetic irritation set up in the alimentary 
mucous membrane. For if the fever continues unabated until the sys- 
tem sinks down, as some times happens, the local inflammation appears 
to be translated to the mucous membrane of the stomach and intestines, 
and thus the patient dies. Now, as we have seen that the mucous mem- 
brane is only a continuation of the skin, and strongly sympathizes with 
it in every inflammation, and as this is the manner of death in such 
cases, it is reasonable to conclude that during the continuance of the 
fever, sympathy of the mucous membrane with the suffering skin is a 
prominent source of the excessive irritation of the nervous system, in 
this variety of symptomatic fever. 

For, though the dire*ct sympathy of the brain with the suffering skin 
is very great through the cerebro-spinal nerves, yet it must be trifling 
compared to that between the brain and the alimentary mucous mem- 
brane. For, in addition to the cerebro-spinal nerves, they are connected 
intimately by the sympathetic and pneumogastric. 

All the organs of the body suffer in such fevers in a greater or less 
degree, as in idiopathic fever ; but probably not generally to so great an 



76 OF FEVER. 

extent, if we leave out of the account the mucous membranes and the 
nervous system, which we have seen suffer frequently immeasurably 
more. Thus we have seen how an inflammation of the skin may develop 
general fever, and lead on to various complications, and even to death. 

Inflammation of the train, produced by direct injury, develops general 
fever. And the first symptoms in such cases do not vary materially 
from other causes of symptomatic fever. 

Let a blow upon the head fracture the skull and directly irritate the 
brain, and we have at first prostration, as in the forming stage of idio- 
pathic fever. The pulse is weak, slow and labored, the face becomes 
pale, the extremities become cold, and a general state of prostration 
follows. But the receding of the blood from the extremities, and its 
accumulation in the larger blood-vessels, finds an undue amount in the 
brain ; and probably a rush of blood to the capillaries of the brain, at 
the point of injury, sets up a local inflammation, even before general 
reaction is produced. For pain in the part continues during the whole 
period of prostration, which argues, at least, that congestion exists till 
the local inflammation is established. And then we have reaction : the 
pulse becomes full, strong, and frequent, the extremities become warm, 
the face, before pale and sunken, becomes full, flushed and red ; in fact, 
we have general fever fully established. 

Now, in a sympathetic fever from inflammation of the brain, all the 
functions of the various organs become deranged, as in other varieties of 
general fever, and, of course, similar consequences follow. The skin 
becomes hot and dry, probably in consequence of the irritability of its 
nerves. And as there is little or no evaporation from the surface to 
conduct away the excessive heat, it accumulates and renders the heat of 
the system excessively oppressive. The secretion of the liver, kidneys, 
and other glands become deranged in a greater or less degree, and thus 
we have a complication of morbid actions, as in idiopathic fever. And 
the irritation thus set up being carried through the cerebro-spinal and 
sympathetic nerves, is immediately felt ; and if, as sometimes happens, 
the brain has not power to rally, the various functions become suspended, 
and life becomes extinct. 

But by far the most direct effect of this injury, of a sympathetic char- 
acter, is felt by the stomach. At the very first, and during the contin- 
uance of the prostration, the stomach appears to strongly sympathize, as 
in the forming stage of idiopathic fevers, only in a greater degree. 
Nausea and vomiting frequently occurs, and is sometimes carried to even 
an alarming extent. Here we find the condition of the stomach during 
the forming and after stages, very similar to what it is in the different 
stages of idiopathic fevers ; in both instances loathing food during the 
early stage, and entirely refusing it during the stage of febrile excite- 
ment. Thus we see how fever is developed by local inflammation of the 
brain, and how the different organs become involved, and especially the 
functions of the stomach. 

But inflammation of the mucous membrane of the stomach and intes- 
tines, or gastro-enteritis, is a cause of sympathetic fever, and probably 
by far the most frequent cause. And in children, indigestion from irre- 
gular eating, or from intestinal worms, is a very frequent cause. Now, 



THE PATHOLOGY OF FEVER. 77 

in either case, no doubt the local irritation of the mucous membrane is 
carried directly to the brain, through the sympathetic, pneumogastric, 
and cerebro-spinal nerves, and hence the febrile excitement which follows, 
and goes on even, sometimes, to a fatal termination. In fact, so strong 
is the sympathy between the stomach and the brain, that an irritation of 
the stomach and intestines of children frequently produce not only general 
fever, but also a local inflammation of the brain itself, which inflammation 
again produces or increases fever, and often terminates in effusion into 
the ventricles of the brain, and even in death. 

The convulsions of children are generally the result of irritation of the 
stomach and intestines being transmitted to the brain and spinal cord ; 
the convulsions being the direct result of the congestion, which conges- 
tion marks the forming stage of the fever which follows. The large 
head of the infant, together with the softness of the brain, causing con- 
vulsions of the voluntary muscles, while the action of the involuntary 
muscle, the heart, is only partially interrupted. It is probable that the 
exercise, during the convulsions of the voluntary muscles, may help to 
relieve the partially suspended involuntary functions, and bring about 
reaction, which reaction, when once established, develops general fever. 
In this way, then, is sympathetic fever produced in children, by irritation 
or inflammation of the stomach and intestines. 

Acrid substances taken into the stomach, as well as crude articles of 
food, irritate or inflame the alimentary mucous membrane, and develop 
fever. Now, if an active irritant, such as boiling water, be taken into 
the stomach, it directly inflames, and gastro-enteritis is produced. Great 
debility and prostration immediately results, in consequence of the influ- 
ence being carried to the brain ; a chill generally follows, in consequence 
of the debility, and this debility may end in the complete prostration of 
the system, suspension of all its functions, and finally in death. But if 
the brain and whole nervous system retain their vitality, reaction is 
sooner or later set up by a renewed activity of the circulation through 
the heart and arteries, and the usual symptoms of fever are developed. 

Gastro-enteritis produced by capillary congestion from suppressed 
perspiration may produce general fever, and this too, from the effects of 
cold upon the extreme nerves of the skin ; in this case, a diarrhoea is 
generally produced by the congestion, irritation, or inflammation, sometimes 
before and sometimes after the general fever is established. If the diar- 
rhoea come on before inflammation, and its fever is established, it is generally 
the direct result of congestion and debility, and being a vicarious discharge 
may prove salutary, and prevent both the local inflammation and the 
fever, but if the diarrhoea come on after the fever is established, it is the 
result of local inflammation, and may be an unfavorable indication. Thus, 
we see, that while symptomatic fever may be produced by local irrita- 
tion or inflammation in any and every tissue and organ in the system, 
gastro-enteritis is probably by far the most frequent cause. As a gene- 
ral rule, symptomatic fevers are more continued than idiopathic, but the 
general fevers produced by gastro-enteritis are in part an exception to 
this rule, for in some cases of gastric, or enteric fevers, there are dis- 
tinct remissions, and regular chills, which may be interrupted and bro- 
ken up, simply by counter irritation, and a regulated diet. 



78 OF FEVER. 

Thus we have seen, that every possible variety of symptomatic fever 
may, and do occur, and that though the forming stage of such fevers, is 
usually shorter than the forming stage of idiopathic fevers, yet the train 
of symptoms are similar, and for the same reasons, that in both cases the 
brain is first prostrated or weakened, and then roused by irritation to an 
excited condition, in which it calls into renewed activity, the depressed 
circulation, and thus reaction, general excitement and fever is the result: 
and also, that while as a general rule, idiopathic fevers are intermittent 
or remittent, symptomatic fevers being the result of local disease, are 
more generally continued ; and finally, that while an inflammation of any 
organ or tissue maybe the cause of general fever, gastro-enteritis is infi- 
nitely the most frequent cause, and also, that while idiopathic fevers may 
produce derangement in all the tissues and organs, gastro-enteritis is by far 
the most frequent complication, and generally exists in a greater or less 
degree, and sooner or later, in almost every case of idiopathic and symp- 
tomatic fever. 

SECTION II.— THE CAUSES OF FEVER. 

The causes of fever are very numerous, and consist of those which are 
predisposing and those which are exciting. Most of the predisposing 
causes may, however, under certain circumstances act as exciting causes, 
and all the exciting causes may, and do act as predisposing causes. 
I will, however, proceed to consider them under the head of predispos- 
ing and exciting causes. 

Predisposing causes. — By predisposing causes, I mean all those influ- 
ences which may depress vitality, or in any way increase the liability of 
fever in any of its forms. Among the predisposing causes are heredi- 
tary predisposition, indigestion, heat, cold, and various imprudences, &c, 
which we will now proceed to consider, in the order in which I have 
named them. 

Hereditary predisposition to fevers, consists in the depression of 
vitality which the human constitution has suffered, from imprudences 
and all the depressing influences which have been operating upon it since 
the creation of Adam. It also includes all the imperfection of organi- 
zation, as well as consequent inability for the performance of their 
functions, of all the organs of the body, the result of physical depravity, 
&c. 

Now, as the contagions are mainly generated in the system, it is 
probable that they were first generated, as well as the predisposition to 
their impressions, by the imprudences of former ages, among which filthy 
habits may have been a prominent one. Thus it was that one fever after 
another arose, as the multiplied deviations from the laws of health 
created not only the predisposition, but also caused to be generated in 
the system the contagion which propagates them. 

Now a predisposition to fevers having been in this way once produced, 
and the contagion which propagates them having been once generated, it 
is probable that this predisposition is transmitted from one generation to 
another; only requiring the contact, in some way, of the contagion 
itself to develop each peculiar febrile affection. And it should be 



THE CAUSES OF FEVER. 79 

remembered that the predisposition has thus become so strong, that most 
and probably all the contagious fevers now frequently arise spontan- 
eously or without an exposure to the contagion generated in the system 
of a person laboring under the disease, in the precise manner in which 
they first arose. 

Thus it is no doubt that the human family have acquired a predisposi- 
tion to the febrile affections, and have caused to be generated in the system 
the contagions which produce the contagious fevers. And thus it may 
continue to be, till by a rigid observance of the laws of health, the 
human constitution shall have been regenerated, and thus the internal 
susceptibility to the fevers become destroyed ; and the external cause 
or poison which propagates them annihilated or rendered harmless. 

It is then a lamentable fact, that the accumulated imprudences of the 
human family transmitted from one generation to another, have 
placed us of the present day in a condition of physical imperfection, 
which renders us liable not only to the contagious fevers, but also to a 
great variety of non-contagious febrile affections. And though by pru- 
dence on our part we may avoid in many cases a frequent attack, yet it 
must be confessed that we are predisposed and always liable to an attack. 

And now, although we cannot directly destroy the acquired predispo- 
sition to fevers, or the contagions or poisons which produce them ; we 
can, by a due regard to cleanliness, pure air, and careful removal of the 
animal excretions, render them milder and less frequent ; and when the 
laws of health shall have been thoroughly understood and rigidly obeyed 
for a reasonable time, I verily believe that the acquired predisposition 
to the contagious, as well as to all other fevers, will be permanently de- 
stroyed, and the causes which now appear to produce them, may perhaps 
be annihilated, or rendered comparatively harmless. Till this very de- 
sirable state of things can be brought about, we have got to inquire into 
the causes of fever as best we can, and lighten as best we can the burden 
of common misery. Let us then proceed to inquire further into the 
predisposing causes of fever. 

Indigestion, or any derangement in the digestive organs or functions 
may predispose to fever. This may be so by cutting off the proper 
nourishment ; in this way reducing the blood, and through the blood 
debilitating the brain and whole nervous system. Indigestion may also 
introduce into the blood an impure chyle, which may not only fail to 
properly nourish, but may act as a direct irritant to the cerebro-spinal 
system ; or the crude articles of food which are liable to pass along the 
intestines, in cases of indigestion, may by irritating the alimentary mu- 
cous membrane, increase the liability to sympathetic fever ; or indiges- 
tion may predispose to fevers, by producing constipation. It is probable 
however, that the constitutional debility that indigestion produces, con- 
stitutes the main predisposition to fever which attends it. For no sooner 
is the general strength of the system lowered, than the various functions 
become impaired, and the brain and whole nervous system grow irritable, 
and in a condition to receive impressions from any febrific agent which 
it may chance to encounter. 

Heat may act as a predisposing cause of fever, especially as it is liable 
to prostrate the powers of the system, and by the copious exhalation 



80 OF FEVER. 

which it is liable to produce from the skin, it may rob the blood of its 
watery parts, and thus hinder its free passage through the capillaries ; 
and thus impairing the functions of the various organs, may predispose 
to fever. Exposure to undue heat may also cause the liver to secrete 
an excess of bile, which being poured into the intestines, may act as an 
irritant, and thus predispose to fever. In these, and probably in various 
ways an undue exposure to heat may predispose to fever. 

Cold, may operate in various ways to predispose to fevers; it is pro- 
bable however, that it is mainly by checking perspiration and by produc- 
ing congestion of the brain and spinal cord, that cold becomes more 
generally a predisposing cause of fever. And it is only when cold be- 
comes excessive, or is long applied, that it may properly be regarded as 
a predisposing cause. It acts more generally as an exciting cause of 
fever. 

Various imprudences. — In fact every deviation from the laws of health 
may by debilitating, irritating, and deranging in various ways the organs 
and functions of the body, predispose to fever. To attempt an enume- 
ration of them, would be like attempting to count the " sands upon the 
sea shore," for they are "legion." While then I will not attempt an 
enumeration of them, it may be proper to state, that it is probable that 
intoxicating liquors, licentiousness in its various forms, and latterly 
tobacco, with their attendant vices, are the most prominent influences, 
which undermine the human constitution, depress vitality and thus in 
ten thousand ways, predispose to fever in its various forms. For it is 
well known, that any influence which depresses vitality, predisposes to 
fevers, as well as to all other diseases. 

And now in concluding our consideration of the predisposing causes of 
fevers, it is well to bear in mind, as I have before stated, that they may 
nearly all under certain circumstances act as exciting causes. And 
though I have enumerated separately only a few of the causes which 
predispose to febrile affections, I trust I have said enough to set our minds 
upon the right track in this matter. Let us then proceed to a consider- 
ation of the exciting causes of fever. 

Exciting Causes. — By exciting causes of fever, I mean here those 
imprudences, agents, and influences, which act directly upon the system 
to produce febrile affections. And if in enumerating them I call up some 
which I have set down as predisposing causes, it must be remembered 
that imprudences, agents or influences may act in either way, sometimes 
as predisposing but under other circumstances as exciting causes. 

While then there are really a great variety of exciting causes of fever, 
such as local irritations and inflammations, retained perspirable matter, 
retained bile, retained urine, intestinal worms, irregularity in taking food, 
violent anger, &c, &c. ; the action of which in the main are sufficiently 
clear, I will only consider separately the more prominent exciting 
causes, and from the manner in which these causes act in producing 
fever, a clear inference may be drawn in relation to the action of all 
agents in developing febrile excitement or disease. The more important 
exciting causes then, to which I will call special attention, are heat, cold, 
humidity, electricity, koino-miasmata, idio-miasmata and contagions ; and 
I will take them up in the order in which I have named them. 



THE CAUSES OF FEVER. 81 

Heat, though generally a predisposing, may become an exciting cause 
of fever. This we see illustrated in cases in which there has been a 
previous exposure to intense cold, the reaction in such cases being some- 
times very great. It is probable also that heat may act directly to 
produce febrile excitement, even in cases in which there has been no 
previous undue exposure to cold. This may be produced by the direct 
irritating effects of heat upon the brain and whole nervous system, 
indirectly producing cardiac and arterial excitement ; or the depressing 
influence of heat, if it be but moderately applied may lead to prostration and 
congestion of the brain and spinal cord, and the irritation thus set up, 
may send forth an influence to the heart and arteries which will develop 
febrile disease. While then heat is generally a predisposing, it may act 
as an exciting cause of fever. 

Cold is a very frequent exciting cause of fever, especially if there had 
been a previous exposure to undue heat. Cold may, if applied suddenly 
and of considerable intensity, produce a chill attended with cerebro-spinal 
congestion, which developing an irritation of the brain and spinal cord, 
may send forth an influence to the circulatory system which shall develop 
febrile excitement. It is more generally, however, by checking the 
perspiration and also the action of the liver, and perhaps kidneys ; 
causing to be retained in the blood urine, bile, or more especially per- 
spirable matter, that cold acts in producing febrile affections. For no 
sooner are either of these matters retained in the blood, than they 
irritate the brain, and either directly excite febrile action, or they produce 
first a depression, and then as a consequence, develop febrile excitement. 

Cold may also produce fever by causing to be retained in the system 
the animal heat, which ordinarily passes off with the evaporation of per- 
spirable matter from the surface of the body ; for as the cold checks the 
perspiration, the animal heat which its evaporation ordinarily carries off, 
in a latent state, remains, and probably acting as an irritant to the ner- 
vous and circulatory systems, is liable to produce febrile excitement ; thus 
in these and various ways, cold becomes an exciting cause of fever. 

Humidity too, by checking the perspiration, is liable to become an ex- 
citing cause of fever, in the manner I have already suggested. When the 
respirable matter is retained by exposure to cold, humidity also by letting 
down the electrical state of the atmosphere may so far rob the nervous 
system of its electricity, as to cause a general depression of the nervous 
and circulatory function, which leading to a chill or congestion, and conse- 
quent irritation of the brain and spinal cord, may lead on to a febrile ac- 
tion. 

Humidity may also by acting in these and various ways, gradually 
impair the functions of the various organs of the body, and becoming 
thus deranged, the retained urine, bile and perspirable matters may by 
acting upon the system, debilitated, produce febrile disease. 

Electricity is a powerful excitant to the nervous system, and hence 
as the atmosphere becomes very dry, and consequently highly charged 
with electricity, its action upon the nervous system may be too stimulat- 
ing, and hence, if it produces irritation, it may lead on to febrile excite- 
ment. While then humidity with a low electrical state of the atmosphere, is 
probably a very frequent exciting cause of fever, in persons in a feeble 
6 



82 OF FEVER. 

debilitated state, it should be remembered that a high electrical state 
caused by excessive dryness of the air, may produce febrile affections, in 
some rare cases, especially in strong constitutions, or in those addicted 
to over- eating, stimulating drinks, &c. 

Now, it should be remembered, that the exciting causes of fever which 
I have named, as well as numerous other accidental causes which I need 
not name, produce fevers of a very irregular character, sometimes con- 
tinuing but for an hour, and again passing on for days or even weeks, 
sometimes terminating speedily in resolution, while at others passing on 
and becoming complicated with local inflammations, organic changes, &c. 
Let us now pass on to a consideration of the remaining causes of our 
list which produce fevers of a more definite or specific character. 

Koino-miasmata, malaria, or the paludal poison, as we have seen in a 
previous chapter, are generated in marshy places, in which there is de- 
caying vegetable matter with moisture, exposed to a temperature of from 
60° to 80° Fahrenheit ; and having an affinity for moisture, it ascends 
with the vapor from such sources, and floating along in the lower current 
of the air, being apparently heavier than common air, it is taken into 
the system through the lungs, mouth, and perhaps absorbents of the 
skin, and produces a variety of febrile affections, of greater or less 
severity. 

It is probable that the paludal poison thus taken into the system, 
enters the circulation, and passes as a foreign substance with the blood, 
without any chemical union, or decomposition of the blood. Its action 
is probably directly upon the brain and whole nervous system ; and 
whatever its composition may be, it doubtless directly diminishes nervous 
action, or depresses vitality. If the malaria be in a highly concentrated 
state, and the system be strongly predisposed, there is liable to be de- 
veloped an intermittent, congestive, or some kindred form of paludal 
fever in a very short time, the morbid action of the agent producing 
prostration of the nervous system, with chills, &c, before the different 
functions of the system have become very materially disturbed. 

If, however, koino-miasmata act upon the system in a less concen- 
trated state, and the system is not predisposed to ague or kindred forms 
of paludal fevers, the agent may, by acting with less violence, produce a 
gradual impression upon the nervous system, and by thus hindering a 
proper generation and distribution of the nervous influence, the various 
functions of the body may become deranged, and with this general de- 
rangement, when the system finally sinks down, and there comes a chill, 
the system does not entirely rally and produce an intermission, as in 
intermittent fever, but only a remission, and hence a bilious remittent 
fever is the result. 

Finally, if the malaria be still more diluted, and be thus brought to 
act upon the system in a very moderate degree of concentration, its 
action upon the nervous system is necessarily very slow, and as it pro- 
duces only a slight disturbance of the functions of the various organs, 
we shall get neither intermittent or bilious remittent fevers, but perhaps 
a bilious diarrhoea, dysentery or intermittent neuralgia, as morbid re- 
sults of the paludal agent. Hence it is, no doubt, that in localities 
where but little malaria are generated we have bilious diarrhoea, dysen- 
tery and neuralgic affections ; where a little more are evolved, bilious 



THE CAUSES OF FEVER. 83 

remittent fevers ; and in localities where the paludal poison is formed 
in great quantities, we get ague and other kindred paludal diseases. 

Now, in relation to the distances to which koino-miasmata may be 
carried in the air, and yet produce intermittent, remittent and neu- 
ralgic affections, there may be some doubt. But from careful observa- 
tions which I have made in this locality, as well as in Jefferson county, 
in this State, where I practiced for ten years, I believe that malaria 
may be conveyed in the air, in a state of concentration sufficient to pro- 
duce ague, for a distance varying from one to three miles, depending 
upon the surface, winds, &c; in a sufficiently concentrated state to pro- 
duce bilious remittent fevers, it may pass from three to six miles, 
depending upon the same influences ; and finally, that it may be con- 
veyed in a state of concentration sufficient to produce neuralgia, &c, 
depending upon obstructions, for a distance varying from six to nine 
miles. I have made this estimate with considerable care, and though 
it may not be regarded as an absolute rule, I believe it will generally be 
found, in the main, correct. 

While, then, malaria may thus pass in the air to considerable distances 
when unobstructed, it should be remembered that it will pass but 
a very short distance over water, being probably absorbed ; and that 
rolling grounds, high fences, if made tight with boards, rows of buildings, 
and especially forests, may almost entirely obstruct its passage in any 
part of its course. I have had ample opportunities for verifying these 
statements in this as well as in other localities ; and, as one of them was 
so very plain and decisive, I will mention it, as illustrating the perfect 
obstruction which a forest may afford to the passage of malaria. 

The land, for a few miles north of Geneva, at the foot of Seneca Lake, 
in the State of New York, is rather level, and there is, occasionally, a 
marsh or low wet place, embracing a few acres. On a road which runs 
east and west, about one hundred rods north of one of these marshes, 
ague was never known, though it had been settled for years. But on 
cutting away the forest between the road and marsh, ague speedily made 
its appearance among the inhabitants along the road, as it was rather 
thickly inhabited, and it has continued to prevail there, more or less, 
every season since. 

In malarious districts, then, advantage should be taken of all the 
available circumstances to intercept the poison as far as possible ; and if 
nothing more can be done, a grove of trees may be left or planted between 
a city, village, or house, and a near marsh ; or a high board fence may 
be made, which would doubtless, in many cases, prove a great protection. 
In localities, too, where malaria are generated, as the poison is probably 
brought down by the dews, the inhabitants should not, as a general rule, 
venture out, either early in the morning or at evening, as the danger 
from its influence would be much greater at such times. 

And while houses in such localities should be built on the highest 
situations available, the sleeping rooms should be arranged, as is well 
even in all localities, as near the roof as possible. This gives the ad- 
vantage of, in part, keeping above the malaria, and also secures the 
benefit of the heat of the sun during the day, which evidently, in part, 
destroys the pernicious influence of the agent. 



84 OF FEVER. 

Finally, in malarious districts, where it becomes necessary to live, and 
it becomes impossible to shut off, or in any way get above the agent, fires 
should be made in the sleeping rooms towards evening, and thus the 
malaria may be, in a good degree, destroyed for the time, at least. It is 
also of the greatest importance, in such localities, that strict cleanliness 
be observed ; for if, in addition to the koino-miasmata, there be generated 
idio-miasmata, or an animal poison. The combined effects of the two 
influences upon the human system, I am satisfied, is much greater than 
of either alone, producing, in some cases, the worst possible varieties of 
malignant fevers. 

Idio-miasmata, or the animal effluvia or poisons which result from a 
decomposition of the animal secretions and exhalations, as we have seen 
in a previous chapter, are liable to accumulate in filthy apartments, espe- 
cially in cold seasons of the year, when they are kept closed ; and though 
they may not generally be conveyed to any very considerable distance, 
they are liable to be taken into the circulation through the lungs, stomach, 
and absorbents of the skin ; and, by decomposing, or uniting chemically 
with the blood, are liable to produce fevers of a low typhus character. 

Animal poisons thus generated from the decomposition of animal 
secretions and exhalations, in abodes of filth, may doubtless produce 
genuine typhus, diphtheria, &c. ; and that such effluvia, on entering the 
blood, unites chemically with it, and probably decomposes it, appears 
quite certain, when we take into account the low putrid fevers which they 
evidently produce. 

Now, if this supposition in relation to idio-miasmata be correct, their 
effects are greatly increased by their power of rendering even the blood 
itself a depressing agent. At any rate, they so completely depress 
vitality, that instead of getting intermissions or remissions in the typhus 
and other putrid fevers which they produce, the fevers are of a continued 
character, as we see in pure typhus ; and when we get local inflamma- 
tions, in such fevers, as we do in diphtheria, the exudations are of a dark 
putrid character, evidently composed of decomposed albumino-fibrinous 
matters. 

Among the fevers that idio-miasmata may produce, are typhus, diph- 
theria, plague; and probably either alone, or combined with koino- 
miasmata, this animal effluvia may produce all low putrid fevers of a 
typhus character, of which it may act both as predisposing and exciting 
cause. 

The distance to which this fearful cause of fevers may be carried in 
the air, as I have already intimated, is probably not very great ; but it 
is probable that the effluvia may be carried in articles of clothing to con- 
siderable distances, and yet retain the power of producing putrid fevers. 
The best means of preventing, then, the influence of this agent, is to 
avoid the causes which lead to its formation. 

The enforcement of proper sanitary regulations, the breaking up of 
dens of filth, and securing cleanliness, proper ventilation, &c, would 
doubtless do much to prevent the generation of idio-miasmata ; and as 
the typhus contagion, which is probably generated in the systems of 
patients thus accidentally prostrated by the disease, is not very readily 
communicated for any great distance in pure air, typhus and other kin- 



THE CAUSES OF FEVER. 85 

dred fevers, of which this agent is now so frequent a cause, might be 
rendered comparatively rare diseases. 

The combination of koino and idio-miasmata, as a cause of fevers, is, 
as I have already intimated, a fearful one ; and I make no doubt, from 
careful observation, but that this combination of causes produces all that 
class of malignant fevers which cannot be traced to the animal or paludal 
poisons alone, including yellow fever, and perhaps diphtheria, plague, &c. 
I am satisfied, too, from careful observation, that the systems of patients 
prostrated with paludal fevers, if not kept in a cleanly, well-aired room, 
may occasionally generate the typhus contagion, which shall produce 
pure typhus in its worst, or at least in a malignant form. And this may 
sometimes occur even with every precaution in relation to cleanliness ; 
an instance of which fell under my observation a few years since, while 
practicing in Jefferson county, in this State. 

An elderly lady was prostrated by a bilious fever, which reduced her 
system considerably, during which she was nursed by a lady from ten 
miles north of her locality, and occasionally visited by a lady whose 
home was thirty miles east of hers. After her recovery the two ladies 
went to their homes, one ten miles north and the other thirty miles east, 
and both beyond the paludal influence which had produced her disease, 
which consisted of a marsh which from a closure of its drain had been 
overflowed, and was drying up. Soon after the lady reached her home, 
ten miles north, she was taken with malignant typhus and died. The 
other lady, after reaching her home, thirty miles east, was taken with 
typhus and died. But this is not all : two of her sisters, young women, 
were taken down with typhus and died. 

Now, as there was no typhus fever in either of these localities, it is 
fair to infer that a typhus contagion was generated in the first patient, 
laboring under the paludal fever, which, acting upon the systems of the 
two ladies which attended and visited her, probably in connection with the 
paludal poison to which they were also exposed, produced in them malig- 
nant typhus. In relation to the two sisters of the lady that took the 
fever and died, they had not been exposed to the paludal poison, as the 
locality is one of the most healthy in the State. 

I will only add, in conclusion, that all these families were cleanly, 
their houses capacious and well ventilated, and the patients had all the 
care that wealth could procure or devoted friends could bestow. 

But I must pass on to a consideration of the contagions as exciting 
causes of fevers, which will complete what I have to say, in this place, 
on the causes of fever. 

Contagions, as we have seen in a preceding chapter, consists of those 
peculiar products of disease, whether in a solid, fluid, or aeriform state ; 
which are capable of producing the same disease in another person, and 
of propagating the disease of which they are the cause and effect, 
through any number of unprotected individuals. 

Now, the contagions, whether the product of secretion or exhalation, 
which produce fevers, either in a liquid or solid state, are introduced 
into the system by contact, generally with the skin : but in the aeriform 
state they act through the absorbents of the skin, or they may be recei- 
ved into the system with the air through the lungs ; or probably by be- 



86 OF FEVER. 

coming entangled with the saliva in the mouth, they may reach the 
circulation, and thus produce their effects. 

Now, we have little difficulty in relation to the origin of the con- 
tagions which produce fevers ; when we remember that as with typhus, 
so with all the contagious fevers, they often arise spontaneously, or from 
various imprudences, without an exposure to the contagion generated 
in the system of a patient suffering with the peculiar disease. Thus, 
then, they all arose originally, and thus they may continue to arise, 
as well as by a direct contact of the contagion, till the predisposition to 
them, the imprudences which have led to it, and the contagion which 
propagates them, shall have been all overcome, by better sanitary regu- 
lations, better morals, and in short, by a better observance of the laws 
of health generally. 

The contagions which produce a great variety of fevers, after enter- 
ing the blood, operate rather slowly in some cases probably to change 
the blood, but in all to depress vitality, through their influence upon the 
brain and whole nervous system. The period of incubation then, during 
which the contagion is operating to derange the system and develop the 
disease, varies with the variety of fever, from two or three days to seve- 
ral weeks. 

After the development of the fever, the contagious secretion or ex- 
halation, begins to be formed ; in some fevers however, sooner than in 
others, and the power of communicating the contagion to other persons 
continues either from the body or clothes ; in many cases through the 
whole period of convalescence. 

The distance to which the contagions may be carried in pure air, is 
probably not very great ; ordinarily not passing beyond a few feet, in 
a state of concentration sufficient to produce fevers. But it should be 
remembered, that they may be conveyed in any of their forms, in cloth- 
ing and other materials, for great distances, and still retain even for a 
long time, the power of communicating their peculiar disease. 

It is always best to avoid an exposure to the contagions, especially if 
it may be done without any inconvenience; for even though the persons 
thus exposed, may get the fever at perhaps the best time for himself, 
yet he is liable to communicate it to another at the worst possible time. 
And further, there is always the possibility of finally escaping some of 
them at least. 

Finally, the contagions which produce most of our fevers, become 
harmless, or comparatively so, when brought to act upon persons who 
have had one attack of the disease which has produced them ; the re- 
sult doubtless of some change wrought in the system by the first attack. 
Thus, have I completed what I had to say here, on the causes of fever, 
predisposing and exciting. 

SECTION III.— THE PHENOMENA OF FEVER. 

Having in the two preceding sections of this chapter taken a glance 
at the pathology and causes of fever, we are now prepared to consider, 
or even anticipate, the phenomena which will be developed in febrile 
affections. 



THE PHENOMENA OF FEVER. 87 

Now we find, just as we should have supposed, that as the predisposi- 
tion to fevers is not alike in any two cases, and as the predisposing and 
exciting causes differ widely in different localities, and in the same 
localities at different times, that the phenomena of febrile affections 
differ widely in different epidemics, and also in the same epidemic in 
different individuals. And yet, as there is a certain degree of similarity 
between the constitutions of all mankind, and as there is also a certain 
degree of likeness in the same causes, even in different epidemics, we find 
a degree of similarity in the phenomena of fevers developed from like 
causes. And yet, it must be remembered, that no two cases of fever develop 
precisely the same symptoms. And that no two attacks of fever, even 
in the same individual, developed from the same or similar causes, are 
attended by precisely the same phenomena. And yet the phenomena of 
fevers, comprising the symptoms, course, type and stages of them, admit 
of a general description, as a matter of convenience, almost every case, 
however, being in some degree an exception to the rule. With this 
qualification let us inquire into the phenomena of fever, comprising the 
general symptoms, courses, type and stages, as they are most frequently 
developed. 

The course, type or order in which the symptoms of fever develop 
themselves, admit of division into intermittent, remittent and continued. 
But it must be remembered that while many fevers are remittent, very 
few are strictly intermittent or continued. Now there has been much 
speculation as to the reason why some fevers are intermittent, while 
others are remittent or continued. I think, however, this question 
admits of an explanation, if we will take into account carefully all the 
facts in the case, and use the common sense we have, as we would on 
other subjects. 

If we can find a good reason why the fevers produced by marsh or 
koino-miasmata, are generally of an intermittent character, I think the 
fact that some of them as well as all the fevers produced by idio-mias- 
mata being remittent or continued will admit of an explanation. — If my 
supposition be correct, that the paludal poison enters the blood and 
passes with it through the system as a foreign substance, and without 
chemical union with the blood, we may reasonably suppose that it may 
produce temporary prostration of the system and lead on to a chill, in 
the way I have suggested in a preceding section on the pathology of 
fever ; the febrile reaction being the direct result of the cold stage, the 
sweating stage and the intermission following as a consequence. This 
will account for the first chill. And as the paludal poison is still in the 
blood, and the system debilitated, the system will keep up the intermis- 
sion for one, two, three or more days according to the degree of its 
debility, and then another chill will follow. This regularity in the 
return of the chills being the result, as I apprehend, of the ability of 
the system to keep up its healthy function for just that length of time. 

And this appears more probable when we remember that, if a patient 
be declining in strength while suffering from ague, the chills often anti- 
cipate, while, if the general strength of the patient is improving, the in- 
termissions become longer, the chills at each time occurring a little later. 

If this accounts for the chills in pure ague, as well as for the time of 



88 OF FEVER. 

their occurrence, I think we may find a good reason why some paludal 
fevers are remittent, and others nearly or quite continued. For we have 
only to remember that local inflammation produces general sympathetic 
fever, and, also, that local inflammations are liable to occur in intermit- 
tents, and we have a solution of this difficulty. For, after the paludal 
poison enters the blood, that, or some accidental cause may, and fre- 
quently does, set up some local inflammation before the first chill occurs, 
or else in the fever which follows the first chill, and, in that case, we 
have a symptomatic fever, superadded to the intermittent, which renders 
the fever itself more or less remittent, or perhaps nearly continued, ac- 
cording to the extent and intensity of the local inflammation. 

This solution of the difficulty appears the more reasonable, when we 
remember that a purely intermittent fever often becomes remittent, and 
a remittent continued, by the supervention of local inflammation. 

And also, conversely, that continued paludal fevers often become re- 
mittent, and remittent become intermittent, by the subsidence of local 
inflammation. This, in my mind, is a rational solution of the fact that 
paludal fevers assume sometimes an intermittent, at others a remittent, 
and, occasionally, a nearly continued course. And it also accounts for 
the fact that intermittents become remittents, and remittents continued, 
and the reverse ; and hence, also, the symptoms which arise. 

We have, now, only to explain why fevers produced by idio-miasmata 
are more continued than those produced by the paludal poison, and we 
have a solution of the whole difficulty. 

Now if, as I have already suggested in a preceding section, idio-mias- 
mata, on entering the blood, unites chemically with it, and, also, mate- 
rially changes or decomposes it, we have a clue to the reason why such 
fevers are generally of a continued character. For, if the blood, in such 
cases, is in a dissolved or materially changed condition, we can readily 
see why, after the chill, that ushers in or produces the first febrile reac- 
tion, there should be no intermission, or only an imperfect remission, 
even though no local inflammation exist. For the first chill would not 
occur till this morbid condition of the blood produced sufficient general 
prostration of the system to lead to it, and then, after the febrile reac- 
tion which the chill produces, the blood being changed, the system could 
not be supposed to produce an intermission, if even a remission. 

Having thus accounted for the intermittent, remittent, and continued 
character of fevers, let us inquire into the phenomena developed in the 
symptoms which arise during the progress of fevers through their different 
stages. 

Now the series of phenomena which occur in the system during a 
course of fever, are just what we should naturally suppose when we take 
into account the nature of the physical organization, and also the cha- 
racter of the predisposing and exciting causes. And though the predis- 
position, the predisposing and exciting causes differ, as we have seen, so 
that no two cases of fever develop precisely the same symptoms, even 
though they occur in the same individual, yet most fevers, left to them- 
selves, develop a train of symptoms, at different periods of their pro- 
gress, which, for convenience, we may call " stages of the fever." 

These stages we may call the "forming, the cold, the hot, the declining, 



THE PHENOMENA OE FEVER. 89 

and the convalescent," all of which are attended with symptoms which it 
may be well for us to consider. 

The forming stage of fever includes the period from the time the feb- 
rific agent begins to produce its effects on the system till the first chill. 
This stage may be long or short, depending upon the predisposition of 
the system, and concentration or activity of the exciting cause. If the 
predisposing causes which have been operating in the system have been 
debilitating to a great degree, and the powers of the system thus rendered 
feeble, a moderately concentrated febrific agent may produce such an 
impression upon the S} r stem, that the forming stage may be of compara- 
tively short duration. While, on the other hand, if the predisposition 
and predisposing causes have been slight, a comparatively concentrated 
or active exciting cause may be slow in developing fever. 

The symptoms of the forming stage of fevers are what might be ex- 
pected from a febrific agent in the blood. 

There is loss of appetite, a bitter taste in the mouth in the morning, 
drowsiness, headache, lassitude, wandering pains, a dull heavy pain in 
the back, disturbed sleep, a feeling of coldness in the morning, and slight 
thirst at evening, fretfulness, sunken countenance, dry skin, a sluggish, 
feeble or irritable pulse, loss of energy, and general debility. 

Now it is evident, that the febrific agent going into the blood, as we 
have seen, operates first upon the brain and nervous system, and thus 
deranges the various functions. The loss of appetite, which occurs early, 
is no doubt the result of the disturbance of the brain, the impressions being 
transmitted to the stomach through the sympathetic and pneumogastric 
nerves. The disturbed sleep occurring during the early part of the forming 
stage of fevers is no doubt the result of derangement of the brain and whole 
nervous system, as also, the wandering pains in the limbs, lassitude and 
general debility ; so too of the indigestion, the brain not being able to 
supply sufficient nervous influence to keep up a healthy action of the stomach 
and intestines, the liver too, from the same cause not supplying a proper 
amount of healthy bile. 

The dryness of the skin, too, comes probably from cerebro-spinal irri- 
tation or derangement, together with the general derangement of the 
organs and functions of the body ; so too the lassitude and general debil- 
ity ; and finally, last of all, the power of the heart and arteries gradually 
decline; the blood is not sent with its accustomed force to the extremi- 
ties, and through the capillaries; as a consequence, the extremities 
become cold, the combustion in the lungs and in the capillaries not being 
sufficient to produce a due amount of vital heat; this in turn increases the 
general derangement of the system, and all finally lead on to the chill. 
The heart and arteries appear to be the last of the organs to be brought 
into a morbid condition during the forming stage of fevers, and this is 
not so strange, especially in idiopathic fevers, since the circulation is 
carried on mainly by the ganglionic nerves. 

If, as I have supposed, the febrific agent acts first upon the cerebro- 
spinal system, and through them and the sympathetic, upon the various 
organs, it is natural to suppose that their functions should become de- 
ranged, one after another, and finally the circulation, the most strictly 
vital function, carried on by the ganglionic system of nerves, should be 
the last to fail. 



90 OF FEVER. 

This I think, is generally true not only in idiopathic fevers, but 
also in most symptomatic fevers ; for as I have before suggested, 
the local irritation in symptomatic fever is first transmitted to the 
brain, and then from the brain through the nerves to the various 
organs, the functions of which become more or less deranged, and finally, 
if the shock of the local affection be great, the ganglionic function of the 
circulation becomes implicated and then there is a chill, as in idiopathic 
fever. Hence we see that the phenomena or symptoms of the forming 
stage of idiopathic and symptomatic fevers are similar, and from the 
same or a similar condition of the various functions, but from the nature 
of the cause, the period of the forming stage, of symptomatic fevers is 
much shorter than in the idiopathic. 

The cold stage of fever occupies the second place in febrile affections, 
coming on as we have already seen from the derangement the febrific 
agent has produced on the brain, nervous system, and various organs of 
the body ; all of which, producing debility, general prostration, and 
languor, let down the circulation, and produce a chill or cold stage more 
or less marked. 

As the powers of the brain and whole nervous system, and through 
them the circulation, sink down, the blood does not flow with its accus- 
tomed freedom through the heart, arteries, capillaries, and veins, the 
extremities become shrunken and cold, the surface of the body numb and 
dry, the countenance pale and sunken, the head feels confused, the tongue 
is dry, the pulse becomes small, frequent, and feeble, and nausea and 
vomiting frequently occur. 

The symptoms of the cold stage are what might be expected from the 
debilitated and irritable condition into which the system is thrown during 
the forming stage. But the stage of congestion of the cerebro-spinal 
system, in which cold is one of the leading symptoms, is generally of no 
very long duration. The brain rallies, and through that, as we have 
seen, the heart and arteries. Reaction occurs. The blood is thrown to 
the extremities. The capillaries are filled and become active. The 
surface of the body becomes red. The countenance is flushed. And so 
the hot stage is developed. The most common symptoms of the hot 
stage are augmented heat, a full, quick, frequent and vigorous, or else a 
small and frequent pulse, pain in the head, intolerance of light, dry, hot 
skin, scanty urine, and wakefulness. 

Now all these symptoms result from the excitement and irritability of 
the cerebro-spinal system, calling into renewed activity the before languid 
circulation, by which the blood is forced back to the extremities, and into 
the extreme capillaries, from which it had receded. And while this ex- 
cited action of the heart and arteries continues, the skin, liver, kidneys, 
and other organs, become so far over-excited or irritated as to very ma- 
terially impair their functions for the time, and hence the scanty urine, 
dry skin, and other deranged secretions. 

But this excited action, after continuing for a longer or shorter period, 
reaches its highest point of febrile activity, and a termination, either 
fatal or favorable, results. This point we may call the crisis, or period 
of decision. In rapid, continued fevers, there is but one crisis. And 
there is only one crisis in a single paroxysm of an intermittent fever. 



THE PHENOMENA OF FEVER. 91 

In remittent fevers, we may also regard them as recurring at each remis- 
sion during the stage of declension, till the final crisis, when no more 
febrile paroxysms occur. 

At the crisis, if it be favorable, the various organs resume, to a certain 
extent, their functions. The tongue becomes moist, the urine more 
copious, the secretion of bile more natural, and the skin becomes moist, 
or sometimes there is copious perspiration, and then it constitutes the 
sweating stage. 

The period from the time at which the fever begins to abate its violence 
till convalescence is fully established, may be called the declining stage. 
The duration of this stage varies, according to the character of the fever, 
and the length of time the system has been suffering from the febrile 
affection. 

The period which follows between the termination of the fever and 
complete restoration to health, is properly the stage of convalescence. 
Now the time which intervenes between the termination of the fever and 
perfect restoration to health, may be longer or shorter, according to the 
constitution of the patient, the nature of the predisposing and exciting 
cause, and also the degree of the structural and functional derangement 
of the various organs. 

The symptoms which arise during the convalescence from fevers, are 
such as are developed by a return of all the organs and functions of the 
body to a healthy or normal state. The appetite improves, the skin 
becomes natural, sleep becomes quiet, the countenance appears more 
lively, there is increase of flesh and strength, the mind becomes cheerful, 
and, in short, the whole physical, intellectual, and moral man becomes 
restored to a normal state. 

Having completed our consideration of the phenomena furnished by 
the symptoms which arise during the forming ; the cold, the hot, the 
critical, the sweating, the declining, and the convalescing stages of fevers, 
we may now proceed to the consideration of the other phenomena of 
fevers, and first of the revolution of fevers. 

" The time which is occupied by one paroxysm of fever, and its suc- 
ceeding intermission, or between the periodical exacerbations of fevers 
not strictly paroxysmal, is called the revolution of a fever." " The 
revolution of fevers vary in point of duration, some fevers completing 
their revolution in twenty-four hours, others in forty-eight, while others 
require seventy-two, and some even ninety-six hours." "The form 
which a fever assumes, in this respect, is called its type. So that a fever 
which occupies twenty-four hours from the commencement of one par- 
oxysm to another, is said to be of the quotidian type ; while one which 
revolves every forty-eight hours is of the tertian type ; and when this 
period is extended to seventy-two hours the fever is of a quartan type ; 
and a period of ninety-six hours constitutes the quintan type." But by 
far the most common types are the quotidian, the tertian, and the quar- 
tan, the others occurring only occasionally. 

Now the cause of this phenomena in fevers, as I have before intimated, 
is clear to my mind. For, if the system can sustain an intermission only 
from the close of a paroxysm, on one day, to the same hour of the next, 
a chill will occur every day ; and if the system be rather declining, the 



92 OF FEVER. 

chills will anticipate, but if the general strength is improving the chill 
will occur a little later each day. 

So in those cases in which the chills occur every forty-eight hours ; the 
system retains more vigor, and does not sink sufficiently to produce a 
chill oftener than every forty-eight hours, the chills in these cases anti- 
cipating or postponing according as the vigor of the system is rising or 
falling. The same rule, I am satisfied, will apply in the quartan and all 
other types. The same, also, will apply to all remitting fevers ; only, as 
there is generally, and, in my opinion, in every case of remittent fever, 
a local inflammation, the system can only sustain a remission instead of 
an intermission. And as the local inflammation is so very liable to 
change, the remissions are generally less regular in their return and 
length than the intermissions in pure ague. 

In intermittent fevers of the quotidian type ; the chill generally comes 
on in the morning. In tertians, it generally comes on about noon. But 
in the quartans, they occur more frequently towards evening. At least, 
such has been the result of my observation. 

In remittent fevers, I have generally observed the remissions to occur 
more frequently in the morning. And this I suppose, is owing in part, 
to the absence of light, and other causes of excitement, during the 
night season. This however, is not an invariable rule. 

In intermittent fevers, we sometimes have what have been called, 
"double tertians," the chills occurring every day; but they differ from 
quotidians, by the paroxysms of alternate days being similar, in relation 
to the time of occurrence, grade, duration, &c. In such a case, the 
chills on Monday and Wednesday, may occur at 10 o'clock, in the fore- 
noon ; while on Tuesday and Thursday, they may occur at 4 o'clock, in 
the afternoon ; so that, though each day has its chill, on the alternate 
days, only, do they occur at the same hour. 

The double tertians however, assume generally a simple tertian type 
before they terminate, the weaker paroxysm disappearing first. 

Much has been said in relation to critical days in fever, or the days 
on which a crisis is most likely to occur. From careful observation on 
this subject, for the past twenty years, I am compelled to believe, that 
the seventh, fourteenth and twenty-first days, are entitled to considera- 
tion in this respect. That is, in all cases of idiopathic fever, depending 
upon a febrific agent, whether that be idio or koino-miasmata ; the tend- 
ency to a crisis is stronger on those, than other days ; other things of 
course being equal. And I suspect that such is the case, to a certain 
extent, in symptomatic fevers. This if true may not admit of an expla- 
nation. But, when we remember that the paroxysms of many fevers, 
recur with great regularity for a longtime, it does not appear so strange, 
that the system should predispose to a crisis on particular days, and 
such I suspect may be the case. 

When a fever has run on, till it has reached its height, and a crisis 
occurs, that crisis is either favorable or unfavorable. If it be unfavor- 
able there may be a rapid sinking of all the powers of life : the extrem- 
ities become cold, the skin clammy, the pulse feeble, fluttering, or 
intermittent, the breathing labored, the countenance ghastly, the eyes 



THE PHENOMENA OF FEVER. 93 

dim, the mind wandering, and finally the last breath is exhaled, the 
heart stops, and the patient is dead. 

But if, on the other hand, the crisis be favorable ; the various organs 
of the body resume their functions, more or less rapidly, as the morbid 
condition subsides. Now, during this period, after a favorable crisis, or 
at the very crisis, the skin, kidneys and bowels, are liable to a copious 
or to a preternatural discharge, which as it occurs at or near the crisis, 
is called a "critical discharge." These critical discharges I think, are 
only the result of an improved condition of the system ; the skin, kid- 
neys, or bowels, thus throwing off from the system that which had been 
morbidly retained. 

A gentle perspiration occurring in this way, if it becomes general 
over the body, is a favorable indication, as it shows an improved condi- 
tion of the general powers of the system. So, too a free discharge of 
urine occurring after a long partial suppression, indicates an improve- 
ment in the vital energy, whereby this languid secretion has become re- 
stored or improved. 

A slight diarrhoea, too, occurring at such a time, if there has been 
no gastro-enteritis, is a favorable indication. But great care should be 
exercised in giving an opinion of such a discharge, till the other secre- 
tions and the general symptoms have been carefully observed ; for too 
often, a diarrhoea occurring at this stage of a fever, indicates a neglected 
gastro-enteritis, which would render the prognosis vastly more unfavor- 
able. 

This then completes our consideration of the phenomena which are 
furnished by the symptoms which arise during a course of most cases of 
idiopathic and symptomatic fevers. And though some of the phenomena 
here described, may not always occur with the regularity which I have 
supposed, yet I believe the statements here, are generally correct. 

Having now in my first chapter, considered the nature, causes, symp- 
toms, diagnosis and treatment of diseases, and in the second, taken up 
irritation, congestion, and inflammation; and finally in the present, 
taken a glance at the pathology, causes, audi phenomena of fever ; we 
are prepared to pass on from general to special Pathology and 
Therapeutics. 



CHAPTER IV. 
GENERAL FEVERS 



SECTION I.— INTERMITTENT FEVER. 

Intermittent fever is essentially a disease of the nervous system. In 
fact, so markedly is the cerebro-spinal system the seat of this affection, 
that I seriously question whether it should be regarded as a fever or as 
an intermittent neuralgia. But as very few cases occur in which there 
is not some local complication, and as it is a matter of convenience, I 
have classed it with, and shall proceed to consider it as a fever. 

Intermittent fever assumes generally either the quotidian, the tertian, 
the quartan, or the quintan type. During the forming stage of ague, 
there is loss of appetite to some extent, the nervous system becoming 
irritable, the circulation imperfect, the extremities being cold, and more 
or less pain is felt in the lower portion of the spine. By degrees the 
circulation becomes still more sluggish, the patient yawns, stretches, and 
feels more languid, till finally the circulation sinks down, the blood 
recedes from the extremities and surface of the body, and there comes a 
chill. 

During the cold stage the skin becomes pale, the extremities shrunken, 
the pulse small and quick, the extremities cold and numb, the lingers 
contracted, and the whole surface of the body materially shrunken. 
The breathing becomes hurried and irregular, and there is sometimes a 
hacking cough. Confusion of the mind is very marked at this stage, 
probably from the undue pressure upon the brain. In fact, sometimes a 
complete state of coma occurs, especially in weak, debilitated patients. 
Vomiting frequently occurs at this period, probably from sympathy of 
the stomach with the brain. The mouth, too, becomes dry, and usually 
there is very great thirst. The urine is clear, free, and without sedi- 
ment, as is usually the case in nervous prostration. Thus it is that the 
symptoms of the cold stage develop themselves, varying in different cases, 
more or less, from a period of a few minutes to several hours. 

The rationale of the symptoms of the cold stage is plain, when we 
recollect that the general cause, operating through the blood, produces 
debility of the brain and whole nervous system, which, sinking down, the 
circulation becomes languid, the blood recedes from the extremities, they 
in consequence becoming cold and shrunken, and in fact the whole surface 
cold and contracted. The internal congestion produces the excitement, 
restlessness, thirst, &c. Pressure of blood accounts for the difficult 
breathing, while irritation of the brain is finally set up by the undue 
pressure, and by it the heart and arteries are called into renewed activity. 
The blood is now thrown to the extremities, the minute capillaries are 



INTERMITTENT FEVER. 95 

injected, the pulse is quick and strong, the respiration is less oppressed 
but quick, animal heat accumulates, and thus the hot stage is developed. 

During the hot stage the skin is hot and dry, the thirst urgent, the 
pulse full, strong, and frequent, the respiration free and quick. There 
is usually pain in the head, back and extremities, and the urine is more 
or less scanty. After this hot stage of reaction has continued for a time, 
usually longer than the cold stage, and varying from one to six or eight 
hours, the febrile excitement subsides, and there comes the sweating 
stage. 

The perspiration usually appears first about the head and face or 
breast, and gradually extends over the whole body. The pulse soon 
becomes soft, but retains its fullness. The breathing becomes nearly 
natural. The skin becomes cool, in part no doubt by the evaporation 
from the surface of the body. The urine, though high colored, generally 
deposits a pale reddish sediment. And thus, by degrees, the sweating 
stage passes by. Thus, by the return of the heart and arteries to about 
their natural degree of activity, the free action of the skin and other 
secretions, and a degree of natural action of the brain and nervous 
system, there is brought about a state of perfect apyrexia, or inter- 
mission. 

During the intermission there is generally, in simple intermittents, no 
fever, but rather a condition of languor, the system appearing weaker 
than natural, and easily prostrated or fatigued. There is usually an 
unnatural sensitiveness to cold, and the countenance is pale, but the 
appetite is usually quite good. In simple intermittents, the intermissions 
are nearly perfect, and the various functions are performed with a 
degree of regularity. But there evidently exists a degree of debility of 
the cerebro-spinal system. 

Complications. — But I have said that simple intermittent fever is quite 
rare, for we find, if there is no complication at first, they often soon 
occur, and very much modify the symptoms of every stage, but especially 
of the intermission. We may have, therefore, the simple, the inflam- 
matory, the congestive, the gastric, and malignant. And as I have 
already given the general course and symptoms of the simple variety, I 
will now consider the varieties or complications. 

The Inflammatory. — If, as frequently happens, a local inflammation is 
set up, in some tissue or organ, during the forming stage, or at the first 
paroxysm of fever, that local inflammation very essentially modifies the 
symptoms of the different stages, and also the course of the fever ; hence 
they may be called inflammatory intermittents. As inflammatory affec- 
tions occur more frequently in winter and spring, this variety is more 
frequently met with at this season of the year, and on that account. 

Now, as simple intermittents, as we have seen, are carried through all 
their stages, with only derangement of the blood and cerebro-spinal and 
nervous system, it is reasonable to suppose that any local inflammation 
would essentially modify its symptoms, and such we find to be the case. 
For, in inflammatory intermittents, though the cold stage is about as in 
the simple, yet the hot stage is generally more or less lengthened, the 
heat of the surface becoming very intense, and the pulse strong, hard, 
and full. 



96 GENERAL EEVERS. 

The intermissions, as might be expected, are not perfect. The pulse 
usually remains quick, tense, and accelerated. The thirst is not entirely 
gone, and the heat of the skin often remains higher than natural. A 
slight headache is frequently complained of, and sometimes wandering 
pains in the back and limbs, as well as a short, dry cough. Such are 
the symptoms arising in ague, with inflammatory complications, varying, 
however, with the seat and extent of the local inflammation. 

The Congestive. — Congestive ague generally occurs in weak and very 
debilitated persons, in whom the powers of life are incompetent to 
restore the circulation perfectly, in consequence of which the cold stage 
is very much lengthened, and is attended with great oppression of the 
lungs, vertigo, fainting, and sometimes coma. The hot stage comes on 
slowly, as the heart and arteries appear incompetent to bring up the 
circulation to hardly its natural standard. The countenance remains 
pale and sunken. The skin is only moderately warm. The breathing 
remains somewhat oppressed, and the pulse frequent, small and tense. 

The Gastric. — When the miasm which operates through the blood, 
on the brain and nervous system, is slow in developing fever, and there- 
fore deranges the digestive apparatus, or the stomach, liver and bowels, 
as is frequently the case in the autumnal intermittents ; we have a 
gastric complication which very materially modifies the course, and 
symptoms of the fever, and this may be called the gastric variety of 
intermittents. 

In the gastric variety of intermittents, there is a foul tongue, bitter 
taste in the mouth, pain in the forehead, an icteric hue of the skin and 
eyes, diarrhoea, the urine loaded with bile, a desire for acid drinks, and 
great irritability of the nervous system. 

The malignant. — Malignant intermittents, are such as occur in hot 
climates; a familiar examination of which, is the " Chagres fever," 
which attacked so many Americans a few years since, on the Isthmus, 
on their way to, and from California. Their malignancy is probably 
in consequence of the extreme concentration of the miasmata, together 
with the debilitating effects of excessive solar heat, on such as are unac- 
climated. 

Their peculiarity consists in the excessive nervous prostration and 
decidedly typhus symptoms which occur. Hemorrhages are very liable 
to occur from various parts of the body, and such cases often have a 
rapidly fatal tendency. 

It is quite probable, that idio-miasmata, combine with the paludal 
poison, to render such cases malignant, as there is evidence of more or 
less of a deranged or decomposed condition of the blood. 

Irregularities. — Such, is the general course of intermittent fever; 
and also, the peculiarities of its various complications. But in some 
cases we have instead of the cold stage, a general numbness, without 
much coldness. In others, still there will be a diarrhoea, instead of the 
sweating stage. 

In infants, it is not uncommon for convulsions to occur, at the begin- 
ning of the cold or hot stage, especially if the child has a large head, 
or is in any way predisposed to convulsions. 

Effects of Ague. — The effects of chills are always more or less perni- 



INTERMITTENT FEVER. 97 

cious, and ague may produce in the system a variety of diseases, not of 
an inflammatory character. Apoplexy sometimes results from the 
undue pressure of blood on the brain, during the cold stage of intermit- 
tents. Aneurism of the large arteries, are sometimes no doubt produced 
during the cold stage of congestive intermittents. In one case that fell 
under my observation, I have no doubt but that there was an enlarge- 
ment of the arteries of the brain, produced by congestive intermittent 
fever, which produced a fatal insanity. Paralysis, neuralgia, and con- 
gestion, or other derangement of the spleen, are sometimes the result of 
intermittent fever. 

Intermittent fever, like many other disease, tends, after a longer or 
shorter time, to a spontaneous termination. I believe however, that the 
same rule applies to ague, in that respect, as to any other similar affec- 
tion. If the general circumstances by which the patient is surrounded, 
are such, as to render the system more feeble, and especially the nervous 
system ; the chills generally anticipate a little, and the fever becomes 
more remitting in its tendency, and if sufficient complications arise, the 
fever may become even continued. On the other hand, if the circum- 
stances by which the patient is surrounded, are such as go to improve the 
general condition of the patient, the chills generally postpone a little ; 
the increasing strength, enabling the system to keep up a healthy action 
a little longer each day, till finally, the chills cease altogether, and 
health is restored. 

Prognosis. — In simple intermittents, the prognosis is generally favor- 
able. Death may occur, however, from cerebral or pulmonary apoplexy, 
a fatal case of the latter having occurred in a feeble patient of mine, 
the present season, during the first chill. In postponing agues, or those 
in which the chills come on later each time, the prognosis is of course, 
more favorable than in anticipating, or those in which the chills come on 
earlier; as this indicates either an improvement or a decline in the 
general condition of the patient. 

I have generally noticed eruptions about the mouth in cases that are 
assuming a favorable character ; at least, I have noticed that this seldom 
occurs in cases which are becoming more complicated. 

In the inflammatory complication the danger is very much in propor- 
tion to the parts involved in the inflammation, and its degree of violence. 
And I am satisfied that these local inflammations, when they exist, are 
the cause of the irregularity of ague. A diarrhoea occurring and con- 
tinuing for any great length of time indicates either a congested or in- 
flamed condition of the alimentary mucous membrane, which is always 
an unpleasant complication. 

In the congestive and malignant varieties, delirium, coma, oedema of 
the feet and legs, and passive haemorrhages, are always unfavorable 
symptoms, as well as great prostration during the intermissions. As a 
rule, however, the prognosis in ague is favorable in temperate climates, 
the dangerous complications being an exception to the rule. The only 
fatal case of ague that has occurred in my practice was from apoplexy 
of the lungs, and this occurred during the first chill. 

Causes. — The general cause of intermittent fever is the paludal poison, 

7 



98 GENERAL FEVERS. 

or koino-miasmata, operating, as we have seen, through the blood upon 
the brain and nervous system. 

The varieties or complications, as we have also seen, are the result of 
accidental causes, occurring during the forming stage, or after the fever 
is developed. It is probable, too, that hereditary predisposition favors 
the various complications which sometimes arise. Thus, the irregularity 
of the inflammatory variety is caused by local inflammation in some 
tissue or organ. The cause of the peculiarity in the congestive is heredi- 
tary or accidental debility, together with concentration of the febrific 
agent. The cause of the gastric complication, as I have already hinted, 
is owing, in part, to the slowness with which the paludal poison some- 
times acts to produce its effects on the brain and nervous system, thus 
giving ample time for gastric and biliary derangement to take place. The 
cause of the malignant variety of intermittents, as we have already seen, 
is the combined effects of koino-miasmata and excessive solar heat, and 
probably, also, the additional cause, in some cases, of idio-miasmata par- 
tially changing or decomposing the blood, and thus lessening vital energy. 

The length of time the paludal poison may be operating upon the 
system before it develops fever is exceedingly various. Sometimes the 
fever occurs in a few days or hours after exposure ; but, in other cases, 
not till several weeks or months, depending, no doubt, much upon the 
predisposition, and also the concentration of the miasmatic agent. 

Gastro-enteritis will produce symptoms similar to ague, even when 
there has been no exposure to koino-miasmata, very many cases of which 
have fallen under my observation during the past few years, and one in 
this village during the past few days. But great caution is necessary in 
discriminating between such cases and genuine ague produced by the 
paludal poison. 

Proximate cause. — I have no doubt, as I have before intimated, but 
what the proximate cause of intermittent fever is debility of the brain 
and whole nervous system, by which the vital energy is, for the time, 
prostrated, producing the cold stage, while each succeeding stage is the 
direct result of the one which precedes it. And it appears to me that 
the regularity of the paroxysms furnishes nothing so very strange, for 
they only show, as I believe, the length of time the brain and nervous 
system can carry on or keep up the functions of the system, uninter- 
rupted by a sinking, which sinking produces a chill. Thus, in a quotidian, 
the brain and nervous system have only strength to carry on, uninter- 
ruptedly, the functions of the system, without a sinking, for twenty-four 
hours, while in tertian they can do it for forty-eight hours, and so on. 
Hence, while the strength of the system remains stationary, the paroxysms 
occur at regular periods, and neither anticipate or postpone. But let 
the strength of the system, by some complication, become lowered, and 
the paroxysms will anticipate, thus showing that the brain and nervous 
system is able to keep up the functions uninterrupted for a less time. 
On the other hand, let the general condition of the system be improving 
by the subsidence of some general or local debilitating cause, and the 
paroxysms will postpone, thus showing that the general strength is enabling 
the brain and nervous system to carry on, uninterruptedly, the functions 
of the body for a longer time. 



INTERMITTENT FEVER. 99 

Treatment. — The treatment of ague may be considered under two 
heads : that which is proper during the paroxysms, and that which is 
proper during the intermissions. 

In the simple, or ordinary intermittents, of an uncomplicated charac- 
ter, little or no treatment is generally necessary during the paroxysms. 
But in the congestive and malignant intermittents, in which the vital 
energy is deficient, it is well to keep the patient secured from cold air. 
And sometimes it may be well to give a mild stimulant, to aid the vital 
powers in preventing fatal congestions ; which are liable to occur. If 
this is not done, the cold stage is very much prolonged; and the reaction, 
if it does come on, is weak and inefficient, and the subsequent stage also 
not fairly developed. 

In the gastric variety, in which the digestive organs are very much 
involved, with irritation of the alimentary mucous membrane and acidity 
of the stomach, if vomiting occurs during the cold or hot stage, sinna- 
pisms should be applied over the stomach, and a little camphor and pre- 
pared chalk administered in solution. This may be prepared by rubbing 
pulv. camphor, one scruple, with prepared chalk, ten grains, and then 
adding an ounce of water. Of this a teaspoonful may be given every 
fifteen minutes till the vomiting ceases. If this, however, should fail, 
gtt. xv of laudanum should be given, which, together with the camphor 
mixture, will seldom fail of arresting the vomiting in such cases. 

In all cases in which the cold stage is very much protracted, and a 
special tendency to the brain prevails — such as severe congestion — and 
there is, consequently, imperfect reaction, the head should be elevated, 
and the feet placed in warm water, and warm, stimulating applications 
rubbed along the whole length of the spine. That which I prefer, as it 
is efficient and always at hand, is a decoction of capsicum in vinegar. 
Two or three red peppers may be broken into half a pint of vinegar, and 
then, being covered, it should be steeped for a few minutes, till it be- 
comes quite strong, after which it may be applied a little warm, with a 
soft flannel cloth, along the whole length of the back. 

Those who have never used this means of producing, or hastening re- 
action, in such cases, will be greatly surprised at its effects, it is also 
exceedingly convenient, as it can be used when the stomach would not 
retain the least thing that could operate in this way. It probably acts, 
through the spinal nerves, upon the ganglionic nerves, in consequence of 
which, they call into renewed activity the languid heart and arteries. 
It probably also, by stimulating the spinal cord, lessens the determination 
to the brain, and thus promotes speedy reaction. 

Cold drinks may be used during the hot and cold stages of ague, if 
there is nothing to contra-indicate them ; but they should be used with 
a degree of caution. The drinks during the sweating stage should be 
warm, and of a mild, unirritating character. Warm toast water, or sage 
tea, is what I have generally found to agree best. These are the general 
principles which should guide us in the treatment during the paroxysms 
of intermittent fever; always, however, waiting for a clear indication 
before resorting to any of these remedial agents. We now come to con- 
sider the treatment proper during the intermission. 

Quinine is the remedy for the cure of simple, uncomplicated inter- 



100 GENERAL FEVERS. 

mittents, and is so, because it is a tonic which operates probably directly 
upon the brain and nervous system, giving power and energy to keep up 
the vigor and action of the various functions of the body. It probably 
also destroys the paludal poison in the blood, which has produced the 
disease, and thus renders the cure permanent. 

The latter part of the intermission is the time when the quinine is in- 
dicated. For then it is that the energy of the system begins to decline, 
and the ability of the brain and nervous system to carry on the functions 
of the body begins to be apparent. It is generally best, I think, to 
commence with the quinine about twelve hours before the chill is ex- 
pected, and give two grains in solution every three hours, till four doses 
are taken, and then a dose each hour, till two more are given, which 
makes twelve grains ; the last dose, in that case, would come one hour 
before the time for the chill. This treatment should be continued till 
the chills are arrested, which will generally happen by the second or 
third paroxysm, and sometimes at the first ; no more chills occurring. 

After the chills are arrested, the quinine should be continued in the 
same way, on the days the chills would have occurred, dropping the first 
dose each day till only one dose is given, and that on the hour next pre- 
ceding the time the chill would have occurred. After continuing the 
quinine in this way till only one dose is given, it may be omitted, except 
to give one grain after each meal for seven or eight days. 

Or instead of the quinine in grain doses after each meal, the fluid 
extract of bark may be given, in half dram doses, or one-third, if the 
quinine appears in any way to disagree. By continuing the quinine, or 
bark, in this way, the tone of the brain and nervous system is sustained, 
and in my opinion the miasmata in the blood neutralized ; and thus the 
cure rendered permanent, in most cases at least. 

I have suggested the treatment for pure ague ; but as there are few 
cases in which the miasmata in the blood has not deranged more or less 
the gastric and hepatic functions, I think it is generally best to give one 
dose of blue pills, and follow them in six or eight hours by a half ounce 
of castor oil, or sulphate of magnesia. In the agues occurring in this 
vicinity, during the three preceding years, I have given three blue pills 
at evening, and followed in the morning by the oil, or salts, and then 
given the quinine, in solution, as above suggested. 

I usually take quinine gr. xxx, acid sulphuric aromatic zi and add 
water ^viii. This makes a convenient solution of the quinine; one 
table-spoonful being a dose. With this amount, I have generally suc- 
ceeded in arresting the chills and preventing their return, in the way I 
have suggested, and then had enough left to give in teaspoonful doses 
after each meal for several days. But in a few cases, I have had to use 
more than the thirty grains. I am satisfied from careful observation, 
that the quinine in solution, is much more certain in its effects, and gene- 
rally borne better by irritable stomach. I think therefore, that in ague 
at least it should generally be given in solution, as I have suggested. 

In cases of congestive and malignant intermittents, the quinine should 
I think, be commenced with, in the early part of the intermissions, 
and continued as I have suggested, to a period, one hour before the 
chill is expected, and, after the chills are arrested, it should be continued 



INTERMITTENT FEVER. 101 

in the same way, as in simple ague, only, the doses given after each 
meal, should be at first one and a half or two grains, and later at last 
one grain as first suggested. 

In inflammatory intermittents, or those in which some local inflamma- 
tion exists ; the inflammation should first be subdued by bleeding, cup- 
ping and blistering if necessary. Blue pills, followed by full doses of 
the sulphate of magnesia, or a full dose of calomel, in castor oil, may 
be of very essential service in such cases. Gentle diaphoretics, and the 
free use of warm sage tea should be allowed in most cases. And, when 
the local inflammation is subdued, the quinine should be administered, 
and the treatment continued, as in simple intermittents, guarding of 
course, the irritated organs or parts. 

In the gastric variety, or in cases in which the digestive organs are 
materially involved ; blue pills should always be given, and followed by 
castor oil; or in children, rhubarb with hydg. cum creta in castor oil, 
will often be best. When the gastric complications or derangement is 
subdued, the quinine should be administered, as in simple uncomplicated 
cases, taking care always to prevent if possible, a return of the gastric 
derangement, by a well regulated diet and every means in our power. 

In those cases of gastro-enteritis in children, which develop symp- 
toms very similar to ague ; cupping and blistering over the stomach will 
generally arrest the chills. It is hardly necessary to say, that in such 
cases, quinine should not be given. 

Such, according to my experience is the best method of fulfilling the 
indications, which arise in intermittent fever. But, as quinine is not 
always at hand when ague occurs, at least in some places, it is well to 
remember, that any nervous tonic rightly administered, may arrest 
ague ; the most convenient of which, according to my observation, are 
the following: 

The bark of the willow, (salix alba), or its active principle, salicin 
is a valuable substitute for quinine or bark, for the cure of intermittent 
fever. The bark may be used in substance, or decoction, in the same 
doses, and prepared in the same way, as the Peruvian bark or cinchona. 
The dose of the salicin is about four grains, to be given during the inter- 
mission, as I have directed for the quinine, it generally requiring about 
twenty- five grains, between the paroxysms of intermittents. The willow 
or its active principle the salicin, will often do well, where from some 
peculiarity, the bark or quinine may not agree. It may also be a con- 
venience when the quinine is not at hand. 

The bark of the dogwood, (Cornus Florida), is a very convenient sub- 
stitute for quinine, in the treatment of intermittents. The bark of the 
dogwood may be given in substance, in dram doses, at intervals between 
the paroxysms. — Or, the decoction made by boiling for ten minutes, an 
ounce of the bark in a pint of water. The dose of this, is one or two 
fluid ounces, to be administered during the intervals of ague, the same 
as the quinine or Peruvian bark. 

But when the Cornus Florida is to be used, as a tonic, especially in ague, 
the fluid or solid extract is the most convenient, and should generally be 
used when it can be obtained, or, what in some cases would be prefer- 
able still, is the corniri, its most concentrated active principle. Of the 



102 GENERAL FEVERS. 

fluid extract, the dose is from one to two drams. Of the solid extract 
from five to ten grains, while the dose of the cornin is only about four 
grains. In either of these forms the active principle of the dogwood 
may be very conveniently administered. 

The iron-wood, is another indigenous remedy, which I do not remem- 
ber to have seen noticed; but which I am satisfied is little, if at all in- 
ferior to the Peruvian bark, as a remedy in intermittent fever. A 
strong decoction of the bark, or what is better, of the wood, taken at 
intervals, between the paroxysms of ague, I have known to speedily 
arrest the chills, and permanently cure the disease. Of a decoction 
made by boiling four ounces of the rasped wood in a pint and a half of 
water, down to a pint, doses of from one to two ounces may be admin- 
istered, during the intermissions of ague, in the manner I have suggested 
for the quinine or Peruvian bark. 

Other indigenous plants or vegetables have more or less efficacy in 
arresting ague, among which are the hop, (Humulus Lupulus), the sage, 
(Salva Officinalis,) the plantain, (Plantago major,) capsicum and various 
others of more or less value, which I need not mention. There are also 
various mineral tonics, which are entitled to more or less consideration, 
as remedies in the treatment of ague : among which are arsenic, iron, 
zinc, &c. In obstinate cases of ague, in which the chill comes on very 
irregularly ; Fowler's solution of arsenic, in ten drop doses three times 
per day, becomes a very valuable remedial agent. Care should be taken 
however that the stomach is in a proper condition to bear it ; and also, 
that the remedy be not continued too long. 

Of the preparations of iron, the carbonate, and the prussiate accord- 
ing to my observation are the most valuable preparations of this mineral. 
Of the prussiate, from three to six grains may be administered at a 
dose, and continued during the intermission of intermittents, the same 
as quinine. The carbonate when used in ague, should be given in doses 
varying from ten to sixty grains, according to the nature and urgency 
of the case. In protracted cases, of irregular agues, in which there is 
great poverty of the blood, the preparations of iron become valuable 
remedial agents. 

Of the preparations of zinc, the sulphate and oxide, are the most con- 
venient and reliable, in the treatment of ague. Of the sulphate, two 
grains may be given three times per day, in protracted cases, where 
other remedies are contra-indicated on account of some peculiarity of 
the system, or from a peculiarly nervous condition of the patient. The 
oxide of zinc may be given in ague, in cases of extreme nervous excita- 
bility, in which other remedies have failed, and the chills have become 
very irregular. From five to ten grains three times per day may be given 
with good effect in such cases. I need hardly say, in conclusion, that 
a clear indication should always be had, before any of these remedies 
should be prescribed in intermittents. 

SECTION II.— BILIOUS REMITTENT FEVER. 

Remittent fever is the result of the combined influence of koino-mias- 
mata, and a local irritation or inflammation in some tissue or organ, 
and generally of gastro- enteritis. 



BILIOUS REMITTENT FEVER. 103 

The symptoms of the forming stage of mild bilious remittent fever, 
are very similar to the symptoms of the early stage of intermittent fever. 
A loss of appetite, bitter taste in the mouth, foul breath, scanty yellow- 
ish urine, constipation of the bowels, or diarrhoea, drowsiness, headache, 
pain in the back, restlessness, and general prostration of the system, 
are among the symptoms which are developed, during the forming stage 
of bilious remittent fevers. 

After these symptoms have continued for a few days, gradually in- 
creasing with the general debility, a slight chill usually occurs, in which 
though there may be coldness of the extremities, and chilliness along the 
spine, the general heat of the body appears nearly natural, or accelle- 
rated, especially in the irritated or inflamed parts. After this im- 
perfect chill, during which there is evident congestion of the liver, or 
alimentary mucous membrane, or both, and generally an acceleration 
of the local irritation of the stomach and intestines, reaction follows, 
with a good deal of febrile excitement. 

As the fever becomes established, the pain in the head, back and 
limbs, is considerably increased, and sometimes becomes very severe and 
tedious. The countenance and especially the eyes, assume more or less 
of a yellowish tinge. The tongue becomes covered with a brownish or 
yellowish fur, nausea, and generally bilious vomiting occur, during the 
first twenty-four hours of the febrile excitement. A sense of weight 
is usually felt in the right hypochondrium, and epigastric regions, and 
sometimes a dull heavy pain. 

The bowels become slightly distended, and are more or less tender 
to the touch. And the respiration is more or less oppressed and irregu- 
lar. The urine becomes scanty and slightly tinged with bile. The 
pulse is full and generally frequent, but not very hard and tense. The 
skin is always dry and hot. These symptoms usually continue till the 
following morning, when a slight perspiration appears on the superior 
portions of the body, and sometimes over the whole surface. 

The febrile excitement, very considerably abates, but not so as to 
form a state of opyrexia ; the skin remaining preternaturally warm, and 
the pulse irritable, and frequent. This remission continues from two to 
four hours ; when the febrile excitement rises, with increased activity, 
and continues for a time, usually twenty-four hours, when another re- 
mission occurs. In this way the fever continues with regular revolu- 
tions, of exacerbations and remissions, until it either terminates in a 
crisis, and convalescence, or else assumes a more uniform or continued 
character. 

This is the ordinary course of a bilious remittent fever, in which the 
miasmatic agent has operated slowly, in producing a debility of the brain 
and nervous system ; and at the same time, has brought about a de- 
rangement of the digestive organs, and more or less irritation or inflam- 
mation of the alimentary mucous membrane, or some other tissue or 
organ. This local irritation or inflammation, preventing a perfect inter- 
mission, which the paludal poison would otherwise have produced. 

Type. — Fevers of this character, usually assume either the double 
tertian, or quotidian type, and generally the double tertian. For though 
remissions occur every day, yet they are generally more marked on 



104 GENERAL FEVERS. 

alternate days, at least such has been the result of my observation. The 
exacerbations of a remittent of the quotidian type, usually occur, at 
nine or ten o'clock in the forenoon; -while those of the double tertian, 
occur generally an hour or two later, but this is not invariably the case. 

Though as we have seen the remissions usually occur in the morning, 
yet this is not always the case, for I have known them to occur some- 
times during the night ; or they may occur at any hour. And in some 
cases, in which the local inflammation is very marked, the remissions 
are scarcely perceptible at any hour, the fever being continued in con- 
sequence of the leading character of the local inflammation. 

Remittents, though mild at the commencement, may assume an aggra- 
vated character ; if they continue over nine or ten days. The tongue 
becomes more loaded with a brown fur, and is dry in the middle : the 
skin assumes a deeper tinge of yellow; debility becomes more conspicu- 
ous; the bowels are distended, and tender to external pressure, and fre- 
quently restlessness and almost constant delirium occurs. 

In localities where there exists, a good deal of humidity in the atmos- 
phere, together with the influence of very warm days and cool nights, 
remittent fever sometimes assumes a more aggravated character. The 
cold stage, in such cases is short, but quite marked ; the heat during the 
excitement intense, the thirst urgent, violent pains occurring in the 
back, and frequently vomiting. The remission is very marked, but 
short ; the next paroxysm is generally more violent than the preceding ; 
the eyes become yellow, nausea and obstinate vomiting occurs, together 
with a great oppression, and anxiety in the epigastrium. During the 
second or third remission, a clammy perspiration appears on the surface 
of the body, and in this way the paroxysms continue to recur, until 
either a salutary crisis occurs, or death takes place. 

If the fever continues beyond the tenth or twelfth day, there is very 
great prostration, and the fever becomes more continued. The skin too 
sometimes acquires that stinging heat, called " calor mordax," or else 
becomes cool and cadaverous to the touch. In this aggravated and pro- 
tracted state of the fever, the lips become swelled, the tongue brown, 
or black, the eyes red, the urine dark brown, or entirely suppressed, 
the alvine evacuations reddish and watery, and generally there is a 
tympanitic state of the abdomen, and haemorrhages occasionally occur 
in the last stage of the disease. 

Between the mild and malignant varieties of bilious remittent fevers, 
there is a vast variety of grades, depending upon the degree of concen- 
tration of the miasmatic agent ; the violence of the exciting cause, and 
the degree, nature, and extent of the local inflammation ; in fact no two 
cases develop precisely the same symptoms. 

Now, the general cause operating upon the brain and nervous system, 
to produce this fever, is Jcoino-miasmata ; but that alone would have 
produced as we have seen, intermittent fever. The local inflammation, 
as I have before stated, so changes the general condition, as to prevent 
the fever from assuming an intermittent character and renders it remit- 
tent ; while the organs involved, and the degree and extent of the 
inflammation, accounts for the almost endless varieties of grade, or 
character of this bilious remittent fever. 



BILIOUS REMITTENT FEVER. 105 

The parts most frequently involved in inflammation in this form of 
fever, are the brain, liver, and alimentary mucous membrane. The 
brain may be the primary seat of the local inflammation, but I am satis- 
fied that generally in the cases in which cerebral inflammation is develo- 
ped, there is a decided gastric derangement first, or more or less gastro- 
enteritis preceding it. 

The complications then, which occur, in the forming stage of the fever 
are usually congestion, with irritation or inflammation of the liver, or 
of the alimentary mucous membrane, and of the two gastro-enteritis is 
by far the most frequent in temperate climates at least. 

Gastric. — Now, in the gastric variety, the nature of the local difficulty 
is congestion, irritation, or inflammation of the mucous membrane; 
generally brought about by the combined influence of the paludal poison 
acting upon the brain and nervous system, deranging digestion; and 
also the effects of cold operating to check the exhalation from the skin, 
by which the mucous membrane of the stomach and intestines becomes 
congested. 

The liver too, becomes slightly congested, in consequence of which, 
its secretion becomes more or less acrid, and this being poured into the 
intestines, serves no doubt, to irritate and inflame the congested mucous 
membrane. Gastro-enteritis is thus set up, which producing sympa- 
thetic irritation of the brain, serves in a still greater degree, to produce 
derangement of the various organs, and especially of the liver, stomach, 
and intestines. 

Indigestion, is therefore, among the early symptoms of gastric remit- 
tent fever. There is early, a bitter taste in the mouth, the tongue be- 
ing covered with a yellow mucous fur, which sometimes becomes dry and 
brown. The appetite is impaired very early, and finally becomes entirely 
destroyed, as severe vomiting often occurs. The urine is scanty, and 
tinged with bile. The bowels are tender and distended, and severe pain 
in the back and head, adds to the already suffering condition of the 
patient. The tongue becomes more red ; the alvine evacuations watery and 
reddish; and there is also, generally, a desire for cool acidulated drinks. 
In this way is the gastric variety of bilious remittent fever developed, 
and its symptoms produced. 

Hepatic. — The hepatic complication, in bilious remittent fever, is 
characterized by intense heat, violent pain in the head, and early deli- 
rium, fullness of the right hypochondrium, a clean tongue, and forcible 
vomiting, of a glairy fluid without bile. 

The bowels are confined, during the early stages; but later there is a 
discharge of dark bile from the bowels ; the skin and eyes become yellow, 
all of which, indicate a deranged condition of the liver. 

In the early stages of such cases, there is evidently little or no bile 
secreted, and later, that which is thrown into the intestines is of an un- 
natural irritating character. The full hypochondrium indicates conges- 
tion, while the yellow skin and excessive vomiting, without the presence 
of bile, goes to prove that little or no bile is poured into the intestines, 
at least during the early stages. The dark bilious matter, which passes 
off later in the disease, goes to prove that some derangement has 
existed in the functions of the liver, at least. 



106 GENERAL FEVERS. 

While there is doubtless considerable congestion, irritation, or func- 
tional derangement of the liver, in these cases, I am satisfied that gastro- 
enteritis exists to some extent, from the very first; having become seated 
generally, during the forming stage of the fever, or at the first parox- 
ysm. During a practice of ten years, in a locality where bilious remit- 
tent fevers, especially prevailed, I do not remember to have treated a 
case, however great the hepatic derangement, in which there was not, 
during the course of the fever, evidence of more or less gastro-enteritis. 
And gastro-enteritis has appeared to me to be developed to some extent 
during the forming stage, or at least, with the first paroxysm of fever. 
And, I am also confident, that gastro-enteritis in these cases, is the rea- 
son why the fever does not intermit, but assume a remittent character. 
The local inflammation adding the symptoms of symptomatic, to the 
paludal fever, and thus rendering the fever remittent. 

It has also appeared to me, that the irritation of the brain, when that 
was a leading symptom, was generally the result of sympathy with the 
irritated alimentary mucous membrane. And finally, that in those cases 
in which there was hepatic derangement, that it was produced by a debi- 
lity of the brain, which deranges its functions ; and that the debility or 
derangement of the brain is generally in part, the effect of gastro- 
enteritis, and also, in part the effect of the febrific agent. 

I have been led to these conclusions by careful observation in every 
possible variety of bilious remittent fever common to our climate. I 
was first led to this conviction by noticing the effects of the minutest 
doses of spirits or any kind of irritating stimulant such patients had 
taken. And I have been confirmed in the belief by the fact, that in the 
worst cases of cephalic or hepatic complications, I have usually got 
sudden and permanent relief by counter-irritants over the stomach and 
bowels. 

I have sometimes in this way changed bilious remittents to intermit- 
tents, and in other cases have arrested them altogether, especially if at 
the time there was not a concentrated miasmatic influence prevailing. 
Another, and unmistakable evidence, of the universality of gastro- 
enteritis, in all severe cases of bilious remittent fever, is the fact that in 
nearly all fatal cases, (that have fallen under my observation at least,) 
there occurs a diarrhoea of a character indicating gastro-enteritis. The 
absence of pain is no evidence that gastro-enteritis does not exist. 
And even absence of abdominal tenderness is no positive evidence. For 
an inflammation confined entirely to the alimentary mucous membrane, 
is not necessarily attended with either. 

Causes. — The causes of bilious remittent fever as I have already sug- 
gested, are koino-miasmata and some local irritation or inflammation, 
and very generally of the alimentary mucous membrane. Every symp- 
tom developed in these fevers are just what we might expect, if such 
were the case. The paludal poison acting slowly upon the brain and 
nervous system gradually dibilitates, and acting through the nerves 
derange the various organs by impairing their functions. 

The liver becomes congested, and either too much acrid bile is thrown 
into the intestines, which serves as an irritant to the alimentary mucous 
membrane ; or if the congestion of the liver be very great, little or no 



BILIOUS REMITTENT FEVER. 107 

bile is secreted, and hence the food which is taken, passes undigested 
through the alimentary canal and becomes a source of irritation to its 
mucous membrane. In either case the digestion becomes impaired, too 
much bile producing a diarrhoea, and too little or no bile producing con- 
stipation, and both acting as direct exciting causes of gastro-enteritis. 

If we take into account, too, the fact, that the general cause operates 
to derange the functions of the skin, and that the secretion of the liver 
is very much as the action of the skin, we need not be at a loss to account 
for the bilious derangement that occurs, even when little or no conges- 
tion of the liver exists. 

It should be remembered, also, that such fevers occur most frequently 
at a season of the year when the warm days and cool nights, by checking 
the perspiration, tend to produce congestion, irritation, and inflamma- 
tion of the mucous membrane of the stomach and intestines. 

Another fact should also be remembered, that intestinal worms, or 
gastro-enteritis from any cause, will sometimes produce remittent fever 
without the aid of a miasmatic agent. Now all these facts, together with 
the symptoms which are developed, tend to prove that gastro- enteritis, 
together with the influence of the paludal poison, is the cause of bilious 
remittent fever. And this position is further strengthened by the fact, 
that gastro-enteritis, occurring in intermittent fever, will render the fever 
remittent. And. also, that removing gastro-enteritis in remittent fever 
will frequently change them to intermittents. 

In malignant cases, it is likely that solar heat, and, perhaps, idio- 
miasmata, act, in addition to the above causes, in developing the fever 
and in increasing its malignancy. 

Treatment. — The indications in the treatment of bilious remittent 
fever are very plain, when we take into account the morbid condition or 
true pathology of the disease. The indications are plainly to equalize 
the circulation, and prevent local congestions, in order that the functions 
of the skin and various organs may be called into healthy activity ; to 
remove from the alimentary canal any acrid secretions or irritating sub- 
stances, which may be operating to produce or increase irritation or 
inflammation; to counteract local irritation or inflammation, and espe- 
cially of the alimentary mucous membrane ; and, finally, to counteract 
the febrific agent, and to restore the tone of the brain and nervous system 
— in all cases, of course, watching with due caution any complications 
that may arise. 

If a patient is seen early in bilious remittent fever, during the forming 
stage, or soon after the chill, and febrile reaction has occurred, the fever 
should generally be arrested at once, or in two or three days ; at least, 
such has been my experience during the past few years. At such a 
stage, the patient should have explained to him his real condition, and 
should be encouraged to believe, that, with proper care and a little judi- 
cious treatment, he may be restored to health without going through a 
course of fever, always, however, stating that it is not quite certain. A 
little encouragement of that kind acts like a charm, and sometimes may 
do considerable towards bringing about that very desirable result. 

At such a time, there is a dry skin, a determination of blood to the 
brain, and general derangement of the whole system, and especially of 



108 GENERAL FEVERS. 

the circulation. To equalize the circulation, promote perspiration, and 
relieve the chilliness and heavy pain in the lower portion of the spine, 
the feet should be placed in warm water, warm sage tea allowed, and, if 
there is chilliness, the whole length of the back should be rubbed with a 
warm decoction of capsicum in vinegar. The foot-bath may be continued 
for two or three evenings, as well as the warm application to the back, 
if there is chilliness, and it is grateful to the patient. If the patient is 
a strong man, ten grains of calomel, with twenty grains of rhubarb, may 
be mixed with half an ounce of castor oil, and given at once, and the 
oil repeated, every six hours, till it operates. 

But if the patient be a female, or a man of slender constitution, or a 
young person and rather delicate, two or three blue pills should be given, 
and followed in six hours by half an ounce of castor oil, and this may be 
repeated every six hours, till it operates. But if the patient be of deli- 
cate constitutioD, or if, from any cause, a mercureal is contra-indicated, 
the next best cathartic in such cases, is some preparation of the Podophyl- 
lum Peltatum (mandrake), of this, one dram of the fluid extract, five 
grains of the solid extract, or what may be better still, one grain of the 
podophyllin may be given, and repeated in six hours if necessary. Eor 
young children, I generally give either the leptandrin,* or else hydg. 
cum creta, with a little rhubarb in castor oil, and repeat if necessary. 

Sinapisms should be applied over the stomach and bowels, and made 
to produce a smart irritation, and repeated at evening, for two or three 
days, if necessary. A mild, nutritious, and digestible diet should be 
enjoined, and every source of irritation, both of body and mind, should 
be removed, as far as possible. In this way, bilious remittent fever may 
generally be arrested, if taken in the forming stage, or early after febrile 
reaction is established. 

If the fever has run on for a day or two, or if some irritating drugs 
have been taken, we generally have more local irritation or inflammation, 
and frequently severe vomiting. In that case, the warm foot-bath and 
stimulating friction along the spine, with sinapisms over the stomach and 
bowels, will do much to equalize the circulation, promote perspiration, 
and allay gastric irritation. As soon as the vomiting is thus arrested, 
a cathartic should be administered. If there is a strong tendency to the 
brain, and the patient be strong and robust, ten grains of calomel, with 
twenty grains of rhubarb, may be mixed with half an ounce of castor oil, 
and administered at once, and the oil repeated in six hours if necessary. 

But if the patient is a male or female of slender constitution, I would 
give three blue pills, and follow in six hours with half an ounce of castor 
oil, and repeat it if necessary. Or, if the patient be of a very slender 
and feeble constitution, or a very young child, the Hydg. cum creta, with 
a little rhubarb, may be mixed and administered with oil, and the oil 
repeated if necessary. If, however, a mercurial from any cause is 
contra-indicated, I would give to an adult two grains of podophyllin, and 
follow with castor oil if necessary. Or, if the patient be a young child, 
I would give the leptandrin in oil, and repeat it if necessary, remember- 
ing that the dose of the leptandrin, for an adult, is two or three grains. 

^Active principle of the Leptandra Virginica. Dose of Leptandrin for adults 2 grains ; 
of the fluid extract one dram. 



BILIOUS REMITTENT FEVER. 109 

In some cases, in which there is great functional derangement of the 
digestive organs, without very marked symptoms of inflammation of the 
stomach or brain, an emetic of ipicac may precede the cathartic. But I 
am satisfied, from careful observation, that, in a large majority of cases, 
an emetic is not indicated, and, therefore, would often retard instead of 
hasten the cure. After getting the operation of a cathartic, I would 
continue warm sage tea or toast-water, with more or less milk, as tending 
to promote perspiration and support the declining strength. 

To sustain the system, prevent local congestions, equalize the circula- 
tion, and arrest the fever, two or three grains of the sulphate of quinine 
should be given every six hours, and continued till the fever is arrested. 
During the first two or three days, three or four grains of Dover's 
powder may be given with the quinine, for the purpose of promoting 
perspiration, procuring sleep, &c. Later, and after the perspiration 
becomes profuse, the Dover's powder should be omitted, and one or 
two grains of pulv. camphor given with the quinine instead, for the 
purpose of quieting nervous excitability and helping sustain the system. 

If the heat of the surface becomes very great, the skin may be sponged 
with moderately cool water towards evening, but great care should be 
taken that it be not done unless the skin is hot and dry. If the skin be 
moist, it may be sponged with tepid water if the condition of the surface 
requires it, and it is agreeable to the patient. 

If much gastric irritation exists, a blister should be applied over the 
stomach, and, the skin being removed, it should be well dressed with 
soft wilted leaves, and left to discharge as long as it will. If there arise 
much irritation of the brain, not of a sympathetic character, a blister 
should be applied to the back of the neck, and treated in the same 
manner, that its full effects may be obtained. 

In relation to drinks, I am satisfied that, while there is a hope of 
arresting the fever, warm drinks are decidedly preferable to cold. I 
generally allow warm crust coffee or toast-water, with nearly an equal 
quantity of milk, sweetened or not, as the patient may prefer, as it satis- 
fies thirst, favors perspiration, and affords sufficient nourishment, and, is 
I believe, in the best possible form. 

As soon as the stomach will bear it, I allow arrow-root, toast, or a 
poached egg, in addition to the drink, at regular meal hours. For it is 
on food that we live. And if it can be taken without injury to the ali- 
mentary mucous membrane, in just so far as it is appropriated it goes to 
sustain the powers of life, which are tottering under the debilitating 
effects of a poisonous febrific agent. 

With this plan of treatment, modified, of course, to fulfill the indica- 
tions which arise in each particular case, I believe that most bilious re- 
mittent fevers may be arrested in five or six days, or, if they are not 
arrested, will become intermittent, and so require only quinine, given, as 
I have suggested in simple intermittents, to perfect a cure. 

It may appear strange to some that quinine should be given, in two or 
three grain doses, every six hours when there is a high state of febrile 
excitement ; but I am persuaded, from extensive and careful observation, 
that its effects are most salutary. And when we take into account the 
real condition of the system, in such cases, it is rational to suppose that 
its effects would be salutary. 



110 GENERAL FEVERS. 

For we must remember that the system is laboring under a poisonous 
agent in the blood which has debilitated, and would have produced an 
ague, except for the local irritation, congestion, or inflammation, which 
has been set up in some tissue or organ, in consequence of this debility. 
Now, the quinine, by sustaining the sinking powers of the system, not 
only lessens the liability to, but also absolutely relieves, by equalizing 
the circulation, local congestions, irritations, and even inflammations ; 
and just as we should suppose, by arresting the debility of the system 
which led to them. 

If, as will generally happen, the fever be arrested in this way, the 
quinine should be continued, in diminished doses, during convalescence, 
with such food, taken at meal hours, as the stomach will bear. And as 
the stomach begins to bear a reasonable amount of food, I generally re- 
duce the quantity of quinine to one grain after each meal. Or if the 
quinine is from any cause contra-indicated, I substitute the fluid extract 
of bark, in doses varying from one-third of a dram to a dram. I have 
treated, during the past few years, hundreds of cases of bilious remittent 
fever in this way, with the most satisfactory results ; generally arresting 
the fever in five or six days entirely, or else rendering it intermittent, 
and then completing a cure with quinine, in the way 1 have suggested 
for simple intermittent fever. In some cases, however, if neglected 
early, or, what is worse, badly treated in the early stages, blisters are 
required, not only over the stomach but also over the bowels. If this is 
not done, in such cases, the system may sink into a typhoid state, and 
be protracted for two or three weeks, or perhaps longer. 

In cases which, from neglect or bad treatment, run on to this typhoid 
state, quinine, with camphor blisters over the stomach and bowels, and 
a sustaining liquid, mucilaginous, or perfectly digestible and unirritating 
diet, are clearly indicated. In such a state, two grains of quinine every 
six hours, either in solution, and administered with mucilage, or else in 
powder, with camphor, may be indicated. For food, in such cases, arrow- 
root, cooked in equal parts of milk and water, or else in chicken or 
mutton broth, does very well for a time ; and gradually a poached egg, 
toast, &c, may be allowed during convalescence. 

In the treatment of bilious remittent fevers, after the first cathartic, 
the bowels should be moved once each day, if necessary, by injections 
of equal parts of milk and water, with half an ounce of salt, lard, and 
molasses, administered a little warm. Or if there is not too much pros- 
tration, an occasional dose of castor-oil may be indicated. But no active 
cathartic should be given, generally, after the first dose, and that should 
always be as mild as may be, and yet fulfill the indication. 

In cases in which the stools remain clay-colored after the first cathar- 
tic, or if skin and eyes remain yellow, and the bowels constipated, altera- 
tive doses of calomel, every six hours for a day or two, may be indicated. 
In such cases, a grain of calomel may be given with each dose of quinine, 
till six or eight doses are taken, and then half an ounce of castor-oil ad- 
ministered. Or if a mercurial be contra-indicated, one half a grain of 
podophyllin, or one grain of the leptandrin may be given instead. 

In some rare cases, in which violent congestion, irritation or inflam- 
mation of the brain, or other vital part, exists, general or local bleeding 
may become necessary, and should not be omitted. But as disease is 



SIMPLE CONTINUED FEVER. Ill 

always a condition of debility, in one sense, general blood-letting can 
never be resorted to except at the expense of the general strength, and 
therefore should not be, except when some violent local congestion, irrita- 
tion, or inflammation, demand it, to save the part involved from its effects, 
till such time as the warm foot-bath, friction along the spine, warm drinks, 
and quinine, shall equalize the circulation, and relieve the suffering part. 
I am satisfied, from careful and extensive observation, that the warm 
foot-bath, with warm sage tea, is often more effectual, when there is time 
for them to be used, than general bleeding ; and they have the advan- 
tage of not permanently debilitating, at least to so great a degree. 
And in all cases in which general bleeding might be resorted to, to pre- 
vent fatal congestion, during a chill or cold stage, I am confident that 
the indication may be much more rapidly and effectually fulfilled, by 
rubbing the back with a warm decoction of capsicum in vinegar. In 
local inflammation, in which an immediate relief of the affected organ or 
part is always indicated, the abstraction of blood, by cups, from over the 
part affected, or along that part of the spine supplying it with nerves, 
becomes one of our most valuable remedial agents. 

SECTION III.— SIMPLE CONTINUED FEVER. 

By simple continued fever, I mean that variety of continued fever 
which arises from various causes, such as atmospheric vicissitudes, elec- 
trical influences, stimulating articles of food and drink, overheating the 
system by violent exercise, mental excitement, &c, and finally endemi- 
cal and epidemical influences. Now, as the human system is liable to 
be thrown into a state of febrile excitement, from these various causes, 
I have thought proper to consider the morbid condition under the head 
of Simple Continued Fever, as being the most convenient, and also sav- 
ing a multitude of names, which by no means increase our knowledge. 

It may be thought that the symptoms which are developed by these 
various causes are not identical, and that, therefore, there should be a 
variety of names, to suit each class of symptoms. I think, however, 
that the symptoms developed, by what have been called simple, catarrhal 
and inflammatory fevers, as a class, correspond as nearly as the symp- 
toms of bilious remittent fevers, or most other febrile affections. I shall 
therefore include under this head what have been called the simple, the 
inflammatory, the catarrhal, &c, leaving typhoid, typhus, and yellow 
fevers and diphtheria, for consideration in the following sections. Hoping 
that this classification may be found the most convenient, I will proceed 
to the consideration, in the present section, of simple continued fever, 
without further apology. 

Symptoms. — The symptoms of simple continued fever are just what 
might be expected, from the nature of the various exciting causes which 
operate to produce it. There is at first a feeling of languor, continuing 
for a longer or shorter time, during which the pulse becomes weak and 
sluggish, the respiration slower than natural, the surface and extremities 
become more or less cold, the appetite indifferent ; there is thirst towards 
evening ; restlessness during the night ; headache ; sensitiveness to cold ; 
creeping chills along the back, with a dull, heavy pain in the lumbar 
region ; scanty urine ; dry skin, with a general feeling of indisposition 
to perform mental or corporeal exertion. 



112 GENERAL FEVERS. 

These symptoms may continue from a few hours to several days, ac- 
cording to the nature and activity of the exciting cause, after which 
there is more or less sinking down of the circulation, and then comes a 
chill. The chill may vary from only a slight feeling of chilliness, con- 
tinuing but a few minutes, to a protracted state of chilliness or severe 
coldness ; depending, of course, very much upon the degree of sinking 
of the circulation, and the consequent failure of oxidation or combustion 
in the lungs, and in the capillaries upon the surface of the body. During 
the chilliness, or cold stage, there is yawning, thirst, headache, restless- 
ness, pain in the back, &c, depending very much upon the severity of 
the chill, as well as the nature of the exciting cause. After the chilli- 
ness, or cold stage, has continued for a time, varying from a few minutes 
to several hours, or even days, the heart and arteries are called into re- 
newed activity by the irritation which the chill has produced, and by other 
causes, and then comes on reaction, corresponding, generally, with the 
severity of the chill. 

The surface of the body and extremities becomes warm ; the counte- 
nance flushed; the eyes red; the pulse active, full, and quick ; and there 
is thirst, restlessness, headache, wandering or darting pains in different 
parts of the body ; the urine becomes scanty and reddish ; the skin hot 
and dry, and thus the febrile reaction becomes fully established, and 
continues for an indefinite time, varying from a few hours to several 
days, or even weeks. Thus we may have established simple continued 
fever, of every possible degree of severity, from the slightest degree of 
febrile reaction, following a scarcely perceptible chilliness, to the highest 
grade Of febrile excitement, following a severe and sometimes protracted 
chill, or cold stage. 

In the mildest form of simple continued fever depending upon some 
slight cause, such for instance as mental excitement, there is scarcely 
any sensible chilliness, the fever is slight and generally passes off in a 
few minutes, or hours, leaving only a slight feeling of exhaustion, from 
which the system soon rallies, and the various functions of the body are 
carried on as usual. But in more severe cases of simple continued fever, 
such for instance as occur from sudden atmospheric vicissitudes, the 
febrile reaction may be very considerable, and the fever may continue 
for several days, or even weeks, developing in its course various local 
affections, the most frequent of which are of the respiratory organs, such 
as catarrh, bronchitis, &c. 

In the highest grades of simple continued fever, such as occur in full, 
strong, and robust young people, from active causes, the febrile excite- 
ment may run very high, and, unless arrested, may lead to violent in- 
flammations of the brain, lungs, stomach, bowels, or in fact any organ or 
tissue of the body. And, finally, in the simple continued fever, arising 
from endemical and epidemical influences, we may have for a time more 
or less active febrile reaction, but finally a decidedly typhoid tendency 
of the fever, leading to various local affections of more or less severity. 

We must remember, that while all these local inflammatory affections 
may arise, they are only complications, which are liable to occur during 
a course of simple continued fever ; many cases of which pass on to a 
favorable termination, without any very special local complications. 



SIMPLE CONTINUED FEVER. 113 

Therefore, when these complications do arise, they do not necessarily 
constitute a new variety of fever, but only local inflammations, super- 
vening upon the simple continued fever. As such, therefore, I shall 
consider them, and will now proceed to inquire into the causes of simple 
continued fever. 

Causes. — The causes of simple continued fever are almost innumerable. 
In fact, any general cause capable of producing directly, or after a chill, 
a febrile condition, might be enumerated as a cause, but I will only men- 
tion those causes which are the most prominent, leaving every one to 
seek out the minor ones, as they may be found to operate in each indi- 
vidual case, as they may occur. 

Mental excitement may act as a cause of simple continued fever. This 
we see illustrated in violent fits of anger ; the prostration being marked 
by paleness, and perhaps slight chilliness, of very short duration ; the 
febrile excitement being by far the most prominent, but generally pass- 
ing off in a few minutes, or hours, leaving only a feeling of exhaustion, 
from the overaction of the system. The immediate cause of the paleness 
of the countenance, trembling of the limbs, coldness, &c, in such cases, 
is the shock to the brain and nervous system, producing a transient de- 
bility, during which the circulation and other functions of the body are 
more or less interrupted. This slight depression, during which the brain 
becomes more or less irritable, from undue pressure, is followed, as a 
consequence, by an excited reaction, which is more or less febrile in its 
character, as the shock to the cerebro-nervous system has been greater 
or less. 

In many cases the shock to the cerebro-nervous system is followed by 
almost instantaneous reaction, but in other cases, depending much upon 
the constitution of course, the shock is followed very slowly by reaction ; 
the brain and nervous system not calling up at once the depressed circu- 
lation. Thus it is that mental excitement produces simple continued 
fever. 

Electricity. — If we had always obeyed the laws of health, electricity 
would probably ever be to us a source of health and comfort. But in 
our present state of physical degeneracy, it becomes, no doubt, a fre- 
quent cause of simple continued fever. Electricity tends to an equilib- 
rium between all bodies ; hence, the electricity of the body is very much 
as that of the atmosphere. Now a damp atmosphere is in a low elec- 
trical state, while a dry, or heated atmosphere becomes highly electric. 
If our systems were in a perfect state of health, and neither too sparely 
nor fully fed, these natural changes in the electrical state of the atmo- 
sphere would regulate the electrical state of our bodies, in a manner 
most conducive to health and comfort. 

But a low electrical state of the atmosphere, making a draft upon the 
already low electrical state of such subjects as are of a slender, weak, or 
feeble constitution, still further debilitates ; and, by thus deranging the 
various functions, becomes a predisposing cause of simple continued fever. 
On the other hand, a highly electrical state of the atmosphere, while it 
rather helps the weak, feeble, and debilitated subject, acts, or may act, 
as a direct exciting cause of simple continued fever, in subjects that are 
overfed, or that are addicted, from any cause, to over stimulation ; and 
8 



114 GENERAL FEVERS. 

thus it is that electricity becomes not only a predisposing, but an exciting 
cause, of simple continued fever. 

Atmospheric vicissitudes, or changes from heat to cold, or from cold to 
heat, become not only predisposing, but exciting causes of simple con- 
tinued fever, according to the manner in which the system is exposed to 
them. If the subject be exposed first to severe cold, and then passes 
into a heated atmosphere, the effect is at once debilitating; and thus, by 
deranging the functions of the body, the change becomes a predisposing 
cause of fever. But if the subject be exposed first to a heated atmos- 
phere, and then passes suddenly into cold, the change, by checking the 
cutaneous exhalation, becomes an active exciting cause of simple con- 
tinued fever. It becomes so, in part, by stopping evaporation from the 
surface of the body, and thereby retaining animal heat ; and also, by re- 
taining in the blood, the perspirable matter, which becomes an irritant, 
directly, to the circulatory system, and also indirectly, by affecting the 
cerebro-nervous system. Thus it is, that atmospheric vicissitudes, or 
changes occurring suddenly in the temperature, become not only predis- 
posing, but exciting causes, of continued fever. The fevers thus pro- 
duced from the merest cold, to the most troublesome influenza, have a 
strong tendency to produce congestion, irritation, or inflammation of the 
mucous membrane of the respiratory organs. 

Stimulating articles of food, and drink, by throwing into the blood 
irritating principles, tend to develop simple continued fever. This, 
we see, illustrated in various articles; in some of which it is the quality; 
while in others it is doubtless dependent, in part at least, upon the quan- 
tity taken. 

Violent exercise, by producing languor, and thus deranging the func- 
tions of the body, becomes a cause of simple continued fever. It is pro- 
bable, that over exercise may not only act as a predisposing, but also, 
in some cases, as an exciting cause, of this variety of fever. 

Endemical influences are frequent causes of simple continued fevers. 
It is a fact well understood, that at certain times, in certain localities, or 
continually in some other localities, certain influences prevail which pro- 
duce continued fever. Now the exact nature of these endemical in- 
fluences, we may not always know positively ; yet, by careful observation, 
in relation to the diseases which occur in different localities, we may form 
an idea of the endemic tendency, whether it be exciting, debilitating, or 
malignant. 

It is a fact, that each locality has, not only its peculiar endemical in- 
fluences, which more or less modifies every disease which arises, but also, 
in certain seasons, a transient endemical influence may prevail, for a 
time, and then pass away. Now these endemical influences, whether 
they be vegetable, animal, aqueous, terrestrial or aerial, probably have 
a powerful influence in producing or developing continued fever. And, 
although we may not always be able to ascertain even their source, we 
should remember that they are probably agents, which act upon the 
system through the blood, affecting either directly the extreme nerves of 
the circulatory system, and thereby exciting fever ; or else, by a reflex 
action, affecting the circulation through the irritation they set up in the 
brain and nervous system. 



SIMPLE CONTINUED FEVER. 115 

In some localities, this influence appears to be directly stimulant, or 
irritating ; and then it is, no doubt, an exciting cause of fever. In other 
localities, this influence appears to be debilitating in its tendency, and 
then it becomes a predisposing cause of fever. While in other localities, 
still it appears to be decidedly malignant, and therefore may act both as 
predisposing and exciting causes of continued fever. Transient endemi- 
cal influences depend, doubtless, upon some transient cause ; which, as 
it vanishes, or spends its force, its influence also passes away. 

These endemical causes of disease should not only be thoroughly un- 
derstood, but their peculiar character should always be borne in mind, in 
arriving at the indications, in every possible variety of febrile ; and, in 
fact, all other affections. Hence, we see, that endemical influences, 
though we may not always know their exact nature, are frequent causes 
of simple continued fever. 

Epidemic influences are always prevailing, and either as debilitating, 
irritating, or malignant agents, are producing, modifying, or materially 
controlling, not only febrile, but also every possible variety of disease. 
That epidemic influences depend, in part, upon aqueous, terrestrial, and 
aerial causes, there can be no reasonable doubt ; and yet, the same is 
true of them, whatever they may be, that is true of electricity; and, in 
fact, all the natural causes of febrile affections, that they are mainly 
rendered noxious to us, in consequence of physical degeneracy, brought 
about by disobedience of the laws of health. It is probable, that filth, 
gluttony, tobacco, drunkenness, licentiousness, and their kindred vices, 
have very much to do in producing or modifying epidemical and endemical 
influences ; and also in rendering a community susceptible to these in- 
fluences, when they are once generated. 

Ilence it is, that epidemics, sweeping round the globe, become puri- 
fiers ; not only removing, to a great extent, its cause, but also most of 
its fit subjects, leaving the better disposed of mankind to struggle on for 
a time ; till the inhabitants of the earth, again, by multiplied imprudence 
and degradation, become not only the generators of, but also fit subjects 
for, another mighty epidemic influence, which again sweeping round the 
world, brushes away the offending cause. 

Now whether these epidemic influences are general, passing round the 
globe, or only affecting a continent, an island, or a state, it matters not ; 
they are, as their name implies, upon the people; so that, not only its 
victims, but also the whole people or race where they prevail, are more 
or less under their influence. 

It is this kind of epidemic influence which is so frequent a cause of 
simple continued fever, acting either as predisposing or exciting cause, 
or very likely both. It is, in short, the influence of the sum total of the 
iniquity of the people, in deviating from the laws of health, falling upon 
them, not only to produce febrile affections, but, in fact, also producing, 
modifying, and controlling, to a certain extent, every possible variety 
of disease. 

Its prevailing tendency should always be understood, whether it be 
irritating, debilitating, or malignant; and its influence carefully esti- 
mated, in arriving at the indications, in every possible deviation from 
the standard of health, whether it be in febrile or any other affection. 



116 GENERAL FEVERS. 

It is evident, then, that an influence, so general and searching in its 
effects, must be a very frequent cause of continued fever. 

Other causes might be mentioned of this variety of fever ; but I trust 
enough has been considered to illustrate the principles involved in this 
variety of febrile affection, and to assist the thinking to search out each 
particular cause in every case of continued fever which may arise. I will 
now proceed to consider the nature or pathology of simple continued fever. 

Pathology. — In relation to the nature or pathology of simple continued 
fever, it appears to me there can be no reasonable doubt. In the mildest 
variety of this continued fever, there is probably only a slight prostra- 
tion, or cold or chilly stage, followed by slight reaction, which, however, 
soon passes over, leaving only a feeling of languor. 

The cerebro-nervous system probably being at first slightly prostrated, 
and then more or less irritated, which irritation produces the accelerated 
action of the heart and arteries, or of the circulatory system. The 
depression which follows is doubtless from the exhaustion of slight over- 
action of the system during the febrile state. 

In the more active grades of this continued fever, produced by atmos- 
pheric vicissitudes, electrical influences, &c, there is probably the same 
depression of the cerebro-nervous system, followed by an irritated reac- 
tion. There is also, probably, in addition to this, more or less retained 
perspirable matter, which, passing through the heart, arteries, capillaries, 
veins, &c, irritate more or less directly the inner surface of the whole 
circulatory system, and, through the extreme nerves of the circulatory 
system, also irritate the cerebro-spinal system. This irritation is then 
transmitted through the cerebro-spinal nerves to the sympathetic system, 
and thus the heart and arteries are kept in an irritated state of excite- 
ment, and the fever rendered continued. 

In the highest grades of continued fever, such as are produced by 
sudden changes in the temperature of the atmosphere, in addition to an 
irritated nervous excitability, and retained perspirable matter, &c, we 
have various active or passive inflammations supervening, all of which, 
when they exist, tend to render the original fever continued. And, 
finally, in that class of continued fever depending upon endemical and 
epidemical influences, we have the same pathology, and probably, in some 
epidemics or cases, a morbid febrific agent entering the blood and de- 
composing, modifying, or materially changing it, and thus rendering the 
blood itself an irritant to the circulatory system. 

Or, in other epidemics or cases, there is probably more or less irri- 
tating or poisonous principles entering the blood, and passing Avith it, as 
a foreign substance, irritating directly the vascular system, and through 
its nerves, the cerebro-spinal and ganglionic systems, and hence, by a 
reflex action, the circulatory system. In either case, the morbid febrific 
agent becomes a cause of continued fever. In the one case, passing, as 
a foreign substance through the system, as an irritant, and, in the other 
case, by changing the blood, and thus not only itself acting as an irri- 
tant, but also rendering the blood itself more or less so. 

Such I believe to be the true pathology of simple continued fever. 
And, if it be correct, it explains the cause of the continued character of 
the fever — at least, till such time as local irritation or inflammation is 



SIMPLE CONTINUED FEVER. 117 

set up in some tissue or organ, after which, the local complication would 
render the fever continued, and would also perpetuate it, unless the local 
inflammation is subdued, far beyond what the original cause would have 
done. 

Prognosis. — The prognosis in simple continued fever is generally 
favorable, if we except those produced by certain endemical or epidemical 
influences, which are sometimes of a most fatal and destructive character. 

That form of continued fever which sometimes prevails epidemically, 
under the popular name of "influenza," at certain periods, assumes a 
most malignant character, sweeping oif by thousands subjects " fitted for 
destruction" by their wanton disregard of the laws of health. 

All simple continued fevers are liable to the supervention of local 
inflammations ; and, when they do occur, they become a source of danger, 
according to the parts involved, and also the degree and extent of the 
local inflammation. 

Treatment. — The indications in the treatment of simple continued 
fever are generally very plain, when we take into account, as we should, 
the exact deviation from the standard of health. In the mildest form, 
such, for instance, as arise from a fit of anger, nothing need be done, 
except to quiet the raging element within, and persuade the subject to 
avoid a repetition of the cause if possible ; but if not, to be sure that, in 
"being angry he sins not.' ; In more violent cases, such, for instance, 
as arise from electrical influences, or from atmospheric vicissitudes, there 
is generally an indication to open the cutaneous exhalent vessels, over- 
come local congestions, reduce the activity of the circulation, and, finally, 
to protect the respiratory and alimentary mucous membranes, and subdue 
local inflammations if they arise. 

Now to promote perspiration and reduce the activity of the circulation, 
the warm foot-bath, with warm sage tea, at evening, are plainly indi- 
cated. The feet should be placed in water, at evening, as warm as it 
can well be borne, and, if it be necessary, the temperature of the bath 
may be gradually raised by the addition of hot water, till free perspira- 
tion is produced, or, if need be, till syncope occurs. The feet should 
then be wiped dry, and the patient allowed free draughts of warm sage 
tea, and allowed to go quietly to bed, and, if the fever be in its early 
stages, the patient may very likely awake in the morning well, or with 
only a feeling of languor, which a little rest and a gently nourishing 
diet will soon correct. 

But if the case has run on till local congestions, irritations, or inflam- 
mations occur, though this treatment would still be indicated, it would 
become necessary to do still more. If, as is often the case, the respira- 
tory or alimentary mucous membranes are suffering, in addition to what 
I have already suggested, sinapisms, made of pulverized mustard, three 
parts, flour, one part, mixed together, and wet with warm vinegar, and 
spread upon cotton or linen cloth, should be applied over the chest, and, 
if necessary, over the stomach and bowels. This may be left on from 
twenty to forty minutes, or till the skin looks quite red. 

If the brain suffers materially, cups may be applied to the back of 
the neck, and two or three ounces of blood taken. If the lungs are in- 
volved to any great extent, cups may be applied over the seat of the 



118 GENERAL FEVERS. 

difficulty and also on the side of the spine corresponding with the affected 
part. In this way, cases of considerable activity may generally be ar- 
rested. It is well however, to use the warm foot bath, and sage tea at 
evening, for two or three nights, or till all the febrile symptoms pass off. 

In cases of continued fever, in which the subject is a full robust young 
person, and there is an active exciting cause, and a high grade of febrile 
excitement, general bleeding may be indicated, and when it is, it should 
be resorted to, early after the establishment of febrile reaction. After 
bleeding, the warm foot bath, warm drinks, &c, a cathartic of either 
calomel and castor oil, or of the sulphate of magnesia should be admi- 
nistered, and afterwards repeated if necessary. 

To reduce the activity of the circulation, the veratrum viride may be 
administered, every six hours. The most convenient form for adminis- 
tering this is that of the fluid extract, of which four or six drops may 
be given every six hours. If there be a strong tendency to the brain, 
the antimonial or James's powder may be given every six hours, alterna- 
ting with the veratrum viride, and continued till the fever is subdued. 
If there be much restlessness or irritability, three or four grains of 
Dover's powder may be given with the antimonial powders, and contin- 
ued till quiet is restored. 

The drinks in such cases should be of gruel, barley water, or what in 
many cases would be preferred, crust coffee or toast water. In this 
way, continued fever of the highest grade may often be subdued in three 
or four days, and often sooner if no local inflammation supervenes. But 
if local inflammations do arise, the same treatment should be continued 
and cupping, blistering, fomentations, &c, resorted to in addition, and 
continued till both the local inflammation and the general fever are 
subdued. 

In continued fever, endemic to any locality, or which is only transi- 
ently so, the character of that local tendency should be carefully studied, 
as the indications in the treatment depend of course upon the nature 
of the cause which is operating. If the cause be of an inflammatory or 
irritative character, nearly the same treatment I have already suggested 
will be indicated, and should be resorted to, modified of course to suit 
each particular case. But if, as is often the case, the endemic tendency 
is depressing or malignant, the warm foot bath, friction along the back, 
with warm pepper and vinegar, warm drinks, sinapisms, &c, may be 
indicated, and should not be neglected, being continued if necessary at 
evening, for two or three days. 

A mild cathartic of rhubarb, leptandrin or podophyllin may be given 
or if indicated hydg. cum creta, or even calomel in castor oil may be 
indicated. In such cases however, as mild a cathartic as will be effici- 
ent, should always be selected. 

Having procured the operation of a cathartic, a tonic is generally in- 
dicated, and should not be withheld. If only a mild tonic be indicated, 
the fluid extract of columbo, in doses of from twenty to sixty drops after 
each meal may be sufficient. But if the prostration be considerable, from 
half a dram to a dram of the fluid extract of cinchona may be given, 
every six hours, or three times per day, according to the degree of 
prostration. 



SIMPLE CONTINUED FEVER. 119 

But in cases which are of a congestive or decidedly malignant character, 
the sulphate of quinine should be given in solution, in doses varying from 
one to four grains every six hours, and continued till convalescence is fully 
established, and then in diminished doses during the whole period of con- 
valescence. Or, during convalescence, if the quinine should become 
very unpleasant to the patient, the fluid extract of bark, or of columbo, 
may be substituted for the quinine, and given in doses of from one-third 
of a dram to a dram after each meal. Such, then, are the principles 
which should guide in the treatment of simple continued fever, depending 
upon endemic influences. 

In simple continued fever of an epidemic character, the tendency of 
the prevailing epidemic influence should be carefully observed and studied, 
whether it be irritative, depressing, or malignant. Till the character of 
the prevailing epidemic influence can be ascertained, a temporizing, ex- 
pectant treatment should be resorted to, only fulfilling such indications 
as clearly arise, and waiting with patience for those which are to follow. 
But when the epidemic influence is fully understood, indications may 
often be anticipated, and thus much time and suffering saved to the 
patient. 

When the prevailing epidemic, with the endemic influences, are well 
understood, the indications in the treatment of the fevers which they 
produce are generally very plain. They are essentially those which I 
have already suggested as arising in simple continued fever from other 
causes, such as to equalize the circulation, promote perspiration, &c, and 
to sustain the sinking powers of the system. The treatment, then, should 
be much the same as that I have already laid down, such as warm foot- 
baths, warm drinks, and applications along the back, if there is chilliness, 
mild cathartics, and if, as is generally the case, there be a sinking or a 
prostrating tendency, tonics, and generally the sulphate of quinine. 

There is one important fact or principle to be borne in mind in the 
treatment of epidemic continued fevers of an asthenic character. It is 
this. If local inflammations supervene, they generally arise from de- 
bility and the consequent imperfection of the circulation, and, therefore, 
will not admit of general depletion. In such cases, if inflammation 
arises in any tissue or organ of the body, it is an indication for more 
quinine, and it should, on no account be withheld, but continued, in full 
doses, in conjunction with cupping, blistering, fomentations, &c, till 
both the local inflammation and general fever are entirety subdued. 

1 speak advisedly from experience on this subject, having observed and 
treated hundreds of such cases in this way with the most satisfactory 
results. 

This, then, completes what I had to say on the subject of simple con- 
tinued fever. And I will now only add, that while these are the general 
principles, it is important to bear in mind that each case will present 
peculiarities, which must not be overlooked in arriving at the indications 
for a rational treatment. In every possible variety of simple continued 
fever, a reasonable amount of nourishment should be allowed, but the 
greatest possible care should be taken that it be administered in a form 
suited to each particular case. 

In mild cases, in which there is little febrile excitement, a plain, di- 



120 GENERAL FEVERS. 

gestible, and nourishing diet may be allowed at meal hours from the very 
first. But in cases in which there is a high inflammatory fever, there 
will generally be at first little or no appetite for solid food. In such 
cases, toast-water, or crust coffee, with a little milk, should be allowed at 
first, and then, as the febrile excitement gradually passes off, more milk 
may be added to the coffee, till an appetite for solid food returns, when 
it should be allowed in a mild form at regular meal hours during the 
whole period of convalescence. In prostrated or congestive malignant 
cases, crust coffee, from one-third to one-half milk, should be allowed 
early ; and later, if necessary, beef tea, beef essence, chicken broth, &c, 
may be given till solid food may be allowed, when it should be given in 
a plain, digestible, and nourishing form during the whole period of con- 
valescence. 

SECTION IV.— ENTERIC CONTINUED FEVER. 

By enteric continued fever, I mean that variety of continued fever in 
which there is congestion, inflammation, and generally more or less ulcera- 
tion of the alimentary mucous membrane, and especially of the glands of 
Pyer and the solitay glands situated along the small intestines. 

This condition is liable to occur in every possible variety of fever, as 
I have already suggested ; and when it does occur in intermittent, bilious 
remittent, or simple continued fevers, the symptoms of typhoid, or en- 
teric fever are added to those of the original fever. Or, more properly, 
the symptoms of the primary fever, or disease, become merged in those 
of the typhoid or enteric fever. But as typhoid, or enteric continued 
fever is liable to occur without any other regular fever preceding it, as 
cause, it is entitled to separate consideration as a fever. I shall there- 
fore treat of it as enteric continued fever, preferring that to the term 
" typhoid fever." 

Symptoms. — When bilious remittent, or simple continued fevers, 
assume a typhoid or enteric character, there is generally more or less 
tenderness of the bowels, with slight tympanites, and in some cases more 
or less pain in the bowels. There is often a diarrhoea, more or less 
troublesome, restlessness, irritability, and more or less prostration of the 
nervous system ; but the most prominent symptoms are stupor, delirium, 
picking at the bed-clothes, imperfect sight, and dullness of hearing, 
lying upon the back, and sliding down in the bed ; and finally, constant 
stupor, insensibility, and if not arrested, eventually death. 

These symptoms are of course modified by the character of the pri- 
mary fever, and also by the extent of the gastro-intestinal congestion, 
inflammation, and especially ulceration, which has supervened. The 
symptoms which arise, however, in primary enteric continued fever are 
just what that peculiar condition of the alimentary canal would be likely 
to develop, especially if we take into the account the nature and effects 
of the causes operating to produce it. There is generally a slight loss 
of appetite, more or less weariness, and disinclination to perform mental 
or corporeal exertion. There is some thirst, especially towards evening, 
and sometimes a little nausea, with a feeling of heaviness in the stomach 
and bowels. There is a heavy feeling in the lumbar region, and often 
more or less pain, and slight creeping chills along the back. There is 



ENTERIC CONTINUED FEVER. 121 

more or less pain in the head, and especially a dull, lost feeling, which 
the patient attempts but fails to describe. 

After these symptoms have continued increasing for a longer or shorter 
time, varying from two or three to ten or twelve days, more or less 
febrile symptoms are developed. These febrile symptoms may be pre- 
ceded by a marked chill, or they may arise, gradually, without any very 
sensible cold stage, except the general chilliness which prevails more or 
less during the whole forming stage of the fever. In either case, there 
are gradually developed the phenomena of enteric continued fever. There 
is thirst, dry skin, flushed countenance, headache, loss of appetite, irri- 
tability and general prostration of body and mind. The pulse is fre- 
quent, full and strong, or small and compressible. The pain in the back 
and head become more severe. There is more restlessness, and though 
there is a general feeling of drowsiness, little quiet sleep is obtained. 

These symptoms continue on, with either very slight or no remissions, 
for several days ; the pulse becomes more frequent, the skin hot and 
dry ; the countenance wears an expression of gloom ; the tongue becomes 
coated, and more or less clammy ; the stomach becomes irritable ; there 
is often diarrhoea, with more or less pain in the bowels, slight tenderness 
on pressure, and generally more or less tympanites, detected by percus- 
sion over the abdomen ; and in some cases a slight eruption appears. 

But gradually the tongue becomes dark and dry, the abdomen more 
distended, small vesicles, or sudamina, appear upon the chest, and often 
on various parts of the body ; there is delirium, obtuseness of hearing, 
redness of the eyes, and, unless the disease be arrested, the pulse be- 
comes very feeble and frequent ; the patient lies on his back, and gets 
down in bed, picks at the bedclothes, becomes delirious and comatose, 
has retention of urine, and involuntary fecal discharges ; and finally, if 
the disease continues, the circulation yields, there is a cold, clammy 
sweat, the countenance becomes cadaverous, and death closes the scene. 

Or if the disease be arrested, the skin and tongue become more moist, 
the stupor and delirium less, the pulse becomes more regular, the patient 
becomes more rational, the tympanites less, the appetite returns ; and 
thus the patient becomes slowly convalescent. The duration of this 
affection may vary, if left to itself, from one to five or six weeks. 

Diagnosis. — The diagnosis of enteric continued fever is not generally 
attended with much difficulty, if we take into the account the most promi- 
nent symptoms which arise ; as they are peculiar to this form of febrile 
affection. The diarrhoea is an important diagnostic symptom of enteric 
continued fever. According to my observation, it generally prevails 
some time during the forming or subsequent stage of the disease. The 
discharges may vary from two or three to ten or twelve in twenty-four 
hours, and they are attended generally by more or less pain. 

The tympanitic state of the abdomen, occurring as it does, and gradu- 
ally increasing as the disease progresses, is an important diagnostic 
symptom. This symptom usually makes its appearance from the third 
to the sixth or seventh day, but it often increases till near the termina- 
tion of the febrile symptoms, and sometimes even later. The slight erup- 
tion, which generally makes its appearance about the ninth or tenth day, 
upon the abdomen and breast, and extending sometimes over other parts 



122 GENERAL FEVERS. 

of the body, is an important diagnostic symptom when it makes its ap- 
pearance. The sudamina, or small vesicles, about the size of a split 
pea, or smaller, which make their appearance about the twelfth or 
fifteenth day upon the chest, neck, and other parts of the body, are also 
characteristic of enteric continued fever. The headache, occurring early, 
and continuing generally till stupor, delirium, coma, and obtuseness of 
hearing supervene, is more or less characteristic of this enteric affection, 
and taken together with these symptoms, becomes an important diag- 
nostic symptom. 

If we notice then, carefully, the slow and insidious mode of attack, 
the dejected countenance, the great prostration of strength, the small 
and frequent pulse, the character of the diarrhoea, the tympanitic state 
of the abdomen, the slight rose-colored eruption, the sudamina, the 
headache, the obtuseness of hearing, the delirium, the coma, the getting 
down in bed, the dry brown tongue ; and, finally, the peculiar gloomy ex- 
pression of the countenance from the very first, we need not be mistaken 
in our diagnosis of enteric continued fever. 

Nature. — In relation to the nature of enteric continued fever, there 
has been a good deal of speculation. But it appears to me, that when 
we take into account the symptoms which are developed from the very 
first, together with the anatomical appearances, there can be little room 
for doubt in relation to the nature of the disease. I am satisfied that 
congestion, irritation, inflammation, and ulceration of the intestinal canal, 
and especially of the glands of Pyer, and the solitary glands along the 
small intestines, constitues, essentially, the morbid condition from which 
most of the symptoms arise. 

It is probable, that typhoid symptoms are seldom developed, unless 
the intestinal disease passes on to ulceration. But the symptoms of the 
forming stage, are just what we might expect from congestion, irritation, 
and inflammation of the intestinal canal ; while those of the latter stage 
are essentially those of ulceration. The headache, stupor, delirium, coma, 
&c, are nothing more than we might expect from this variety of intes- 
tinal disease, the sympathetic derangement, of course, passing from the 
intestines, or alimentary canal, through the pneumo-gastric and sympa- 
thetic nerves, directly to the brain. 

I have repeatedly known an incipient typhoid state arrested, and the 
stupor, headache, delirium, &c, to subside, at once, by the drawing of a 
blister over the stomach or bowels, in cases in which the subsidence of 
these symptoms could not be attributed to anything except the arresting 
of the alimentary, or gastro-intestinal inflammation or ulceration. I 
have also known the diarrhoea as suddenly arrested by counter-irritation 
over the stomach and bowels, which could not reasonably be attributed 
to anything except the counter-irritation subduing the gastro-intestinal 
inflammation or ulceration. Again, I have known irritating articles of 
food, evidently by irritating the alimentary canal, to bring on, rapidly, a 
typhoid state in bilious remittent, and simple continued fevers ; and also, 
to bring on a return of all the typhoid symptoms in convalescent enteric 
fevers. It is a fact, also, that drastic cathartics often immediately 
develop typhoid symptoms, evidently by the irritation or inflammation 
they produce in the stomach and intestines. 



ENTERIC CONTINUED FEVER. 123 

Now with all these facts, and many more which might be men- 
tioned, it appears to me, that there can be no reasonable doubt in rela- 
tion to the nature of typhoid or enteric fever, especially as all the symp- 
toms from the first, are what might be expected to arise from irritation, 
inflammation, and ulceration of the intestinal canal ; involving, of course, 
the mucous membrane, with the glands of Pyer, and of the solitary 
glands, the ulceration sometimes extending through the muscular and 
peritoneal coat of the intestines. 

It is probable, that the symptoms of the early stage may be produced 
by merely congestion, irritation, and inflammation ; but that it requires 
ulceration to develop the stupor, delirium, coma, deafness, &c, which 
constitute the essential symptoms of confirmed enteric fever. But, in 
order to render this matter more certain, it becomes necessary to inquire 
into the morbid appearances presented on post-mortem examination. 

Anatomical characters. — Now it is a well known fact, that in all marked 
cases of enteric continued fever, there is presented, on post-mortem ex- 
amination, a congested state of the mucous membrane of the small, and 
frequently of the large intestines, and stomach. There is also evidence 
of inflammation, more or less general, through the whole alimentary 
canal, not even excepting the stomach and large intestines ; but gene- 
rally, more especially along the small intestines. 

Patches of ulceration may generally be found along the small intes- 
tines, and sometimes in the stomach and large intestines. These ulce- 
rations may pass only through the mucous coat, or they may perforate 
the muscular, and even the peritoneal coat, in some cases ; one interest- 
ing case of which fell under my observation a few years since. But the 
anatomical changes, perhaps the most characteristic of enteric continued 
fever, are the congested, inflamed, and generally ulcerated condition of 
the glands of Pyer, situated along the ileum ; and also the small solitary 
glands of the ileum, occupying mostly its lower portion. These morbid 
appearances are, I believe, nearly always found, to a greater or less ex- 
tent, in all well marked cases of enteric continued fever, and appear to 
point to the alimentary canal as the seat of this truly formidable disease. 

Other morbid appearances are, however, sometimes presented ; such 
as inflammation, or enlargement of the mesenteric glands, enlargement 
of the spleen, a slight softening of the liver and kidneys, and various 
other changes of minor importance ; all of which, I believe, may be re- 
garded as the effect, and not the cause, of the disease itself. 

Causes. — I have already stated that a typhoid, or enteric fever, may 
supervene upon a bilious remittent, or simple continued fever, from any 
cause that will produce ulceration of the alimentary mucous membrane ; 
involving, of course, the glands of Pyer, and also the solitary glands of 
the lower portion of the small intestines. Now, this to my mind, ac- 
counts for the disease when it occurs as a complication, in more simple 
febrile affections ; the morbid condition, in such fevers, very much pre- 
disposing to this gastro-intestinal ulceration, which being once produced 
and established, the symptoms of the primary fever are merged in those 
of enteric continued fever. 

But in primary cases of enteric fever, there are generally operating 
some predisposing, as well as exciting cause of the disease, independent, 



124 GENERAL FEVERS. 

of course, of any preceding febrile affection. It is probable, then, that 
any debilitating cause may operate to predispose the system to enteric 
fever ; such as damp sleeping rooms, impure confined air, insufficient cloth- 
ing, scanty or unwholesome supply of food, impure water, filth, great 
depression of spirits, taking food at unseasonable hours, the use of to- 
bacco, drunkenness, licentiousness, and various other like causes. By 
any, and all these causes, the system may be reduced to a condition in 
which the fluids, and solid tissues of the body, are in a more or less de- 
ranged state ; and, as the cutaneous exhalation becomes less, the alimen- 
tary mucous membrane becomes at first congested, then inflamed ; and, 
finally, more or less ulcerated, developing the symptoms which arise as 
the disease progresses. 

In many cases, the disease appears thus to come on insidiously, with- 
out any very marked active exciting cause. But there may be some 
irritating exciting cause, as I have known in some cases ; such as stimu- 
lating articles of food or drink, or indigestible food, sudden exposure to 
cold damp air, wet feet, sudden changes in the electrical state of the 
atmosphere, &c. These exciting causes, however, when they do operate, 
probably only hasten on what would otherwise occur in a little longer 
time. I have known, however, green chestnuts and other such indi- 
gestible substances to produce enteric fever, in cases where there did not 
appear to be any very marked predisposition to the disease. Having 
now inquired into the symptoms, diagnosis, nature, anatomical characters, 
and causes of enteric continued fever, I think there should not be room 
for reasonable doubt in relation to its pathology. 

Pathology. — It appears to be plain that the typhoid state, into which 
other fevers pass, are from the enteric inflammation and ulceration which 
supervenes ; the deranged condition of the fluids and solids of the system 
constituting the predisposing, and the enteric ulceration the essential 
condition of the typhoid state. And it also appears to me reasonable, 
that in primary enteric fever a deranged condition of the solids and 
fluids of the body, produced by any of the causes I have enumerated, 
such as filth, bad air, unwholesome food, intemperance in eating and 
drinking, licentiousness, exposure and want, may act as predisposing 
and exciting causes of enteric fever. And finally, that in cases in which 
there is no very marked predisposition, enteric fever may be produced 
by crude indigestible articles of food, producing directly inflammation 
and ulceration of the alimentary mucous membrane, involving, of course, 
the small glands along the small intestines. In this latter case, however, 
it is probable that the local irritation of the alimentary mucous mem- 
brane, very soon,' by interrupting digestion, produces the requisite 
changes in the fluids and solids of the system, and so enteric continued 
fever is the result. 

This, then, brings us to the essential pathology of enteric continued 
fever : a deranged or changed condition of the fluids and solids of the 
system, and gastro-intestinal ulceration, involving the small solitary 
glands and glands of Pyer, situated along the small intestines, and 
chiefly along the lower portion of the ileum. And, while I am confident 
that this is the real truth of the matter, I am satisfied, from careful 
observation, that the system, while laboring under typhoid or enteric 



ENTERIC CONTINUED FEVER. 125 

fever, may, and frequently does generate a virus or morbid poison, which 
will produce directly genuine typhus fever, and very strongly predispose 
to enteric continued fever.* 

Prognosis. — The prognosis in enteric continued fever is generally not 
very unfavorable, at least if proper treatment be resorted to in season. 
In those typhoid or enteric fevers supervening upon bilious remittent or 
simple continued fevers, the danger depends much upon the general de- 
rangement produced in the system by the primary fever, for I believe 
the typhoid complication may generally be arrested if attended to imme- 
diately : at least such has been the result of my observation. 

In primary enteric continued fever, the danger depends much upon 
the extent and degree of the abuses of the system which has led to it. 
If the abuses of the system have been very great, and thus the derange- 
ment of the fluids and solids of the system very considerable, it offers a 
formidable barrier to a resolution of the gastro-intestinal inflammation 
and ulceration. But in cases in which the exposures have been slight, 
and thus the integrity of the solids and fluids not very materially im- 
paired, I have generally found the disease to yield to proper and judicious 
treatment, if timely applied. 

Treatment. — In arriving at a rational treatment we have only to take 
the deviation from the standard of health, and we have the indications, 
to fulfill which we need only to make the best selection of remedies, and 
apply them judiciously, and we shall have done our duty. 

Now the deviation from health is evidently, as we have seen, a de- 
ranged condition of the fluids and solids of the system, such as grow out 
of imprudence, exposure, filth, &c. Great general debility, and conse- 
quent derangement of the functions of the body, and congestion, in- 
flammation, and ulceration of the alimentary canal, but more especially 
of the minute glands, situated along the lower portion of the small 
intestines. — The indications, then, are plainly to sustain the sinking 
powers of the system, arrest the ulceration, subdue the intestinal in- 
flammation, and restore to a healthy state the functions of the body, 
and especially that of the skin. 

When typhoid or enteric fever supervenes upon bilious remittent or 
simple continued fever, the general indications in the treatment of the 
primary fever may not be very materially changed, except in so far as 
the intestinal ulceration is concerned. In such cases, I have generally 
succeeded in arresting the typhoid symptoms by applying a blister over 
the stomach, if it is done early, or blistering the stomach and bowels, if 
neglected for a time. In such cases, as soon as the stupor, delirium, 
diarrhoea, &c, make their appearance, a blister, the size of the hand, 
should be applied to the epigastrium, and left on till the skin all raises, 
when it should be removed, the skin taken off clean, and then the sore 
should be dressed with soft wilted leaves, and kept running as long as it 
will, the leaves being changed every six hours. 

As soon as the blister begins to discharge, if the patient was not taking- 
it before, the sulphate of quinine should be given in two or three grain 
doses every six hours, to sustain the sinking powers of the system, and 

* See cases reported by me in the Buffalo Medical Journal, Vol. viii., page 354, in the 
year 1852. 



126 GENERAL FEVERS. 

to counteract internal congestions, and especially that of the alimentary 
mucous membrane. The quinine may be given in powder or solution ; 
in either case it should be taken with mucilage of gum arabic, to prevent 
any irritating effect upon the alimentary mucous membrane. 

As the first blister gets nearly healed, if the tympanitis, diarrhoea, 
stupor, &c, have not been entirely arrested or corrected, a blister of the 
same size should be applied to the abdomen, directly below the umbilicus, 
and made to draw well, and it should be treated as the other, taking care 
that it be kept moist and well covered with soft wilted leaves. The 
quinine and mucilage should be continued, and a reasonable amount of 
such nourishment as the stomach will bear should be given, and, as the 
blister begins to discharge, the tympanitis, diarrhoea, stupor and delirium 
will generally entirely subside ; at least, such has been the result of my 
observation. In fact, so uniformly has this been the result of my obser- 
vation, that I have become accustomed to feel a degree of certainty in 
such cases that I seldom do in any others. 

The only exceptions to a rule has appeared to me to be from perfora- 
tion, or those extreme cases of intestinal ulceration, in which a wasting 
diarrhoea has brought the system too low to be sustained by the amount 
of nourishment and quinine the stomach will bear. So much, then, for 
the treatment of secondary typhoid, or enteric fever. Let us now pro- 
ceed to consider the best methods of fulfilling the indications in primary 
enteric continued fever. 

In the treatment of primary cases of enteric continued fever, the de- 
bility has generally so far deranged the gastric and hepatic functions, 
that a cathartic becomes indicated. That which I prefer in such cases, 
for adults, is two or three blue pills, followed in six hours by half an 
ounce of castor oil. For children, the hydg. cum creta, mixed with a 
little rhubarb, or leptandrin, may be given in oil, and the oil repeated in 
six hours if necessary. 

The warm foot bath should be used, morning and evening, for two or 
three days, and warm sage tea allowed ; and, if there is chilliness, with 
a dull heavy pain in the lumbar region, the back should be bathed with a 
warm decoction of pepper in vinegar. This application to the back, in 
such cases, relieves the dull heavy pain in the back, and produces an 
agreeable glow of warmth, and often sends forth a gentle perspiration, 
especially with the aid of the warm sage tea ; while the warm foot bath 
not only favors this, but also lessens the tendency to the brain, and also 
to the alimentary mucous membrane. 

To counteract the gastro-intestinal inflammation, and arrest the inci- 
pient ulceration, sinapisms should be applied over the whole abdomen, 
morning and evening, for a day or two, and allowed to irritate, but not 
to blister. The patient should be directed to take a plain, nourishing, 
and digestible diet, if the stomach will bear it, but if it will not, warm 
toast water, with an equal quantity of milk, may be allowed. Or what 
I prefer, is the crust coffee, one-third, or one-half, milk. This may be 
made, by toasting brown, a slice of bread, and then pouring upon it a 
pint of boiling water, and then adding from half a pint to a pint of milk, 
according to the amount of nourishment required. This may be sweet- 
ened, or not, to suit the taste of the patient ; and in either case, it is a 



ENTERIC CONTINUED FEVER. 127 

most pleasant, convenient, and safe method of administering nourishment 
in such cases, and in fact, in all cases in which nothing but drinks can 
be borne. 

Now I am satisfied, that nearly every case of incipient enteric fever may 
be arrested in this way, if attended to in season, with perhaps a grain of 
the sulphate of quinine in solution after each meal, or every six hours, 
for five or six days. The bathing of the back equalizing the circulation, 
the foot bath and warm sage tea promoting perspiration, the cathartic 
improving the gastric and hepatic function, the mustard counteracting 
and arresting the intestinal inflammation and ulceration ; while the nou- 
rishment and quinine arrest the sinking tendency, and restore the tone 
of the nervous system, and with it the functions of the whole body. 

But, unfortunately, most cases are neglected during the incipient stage, 
and as they are, the chances of thus arresting, at once, enteric fever, is 
of course lessened. In cases, then, that have been neglected, or what is 
worse, badly treated, that which I have suggested should be resorted to, 
modified, of course, to fulfill the indications which arise in each case, 
and much more may become necessary. If, after the operation of the 
cathartic, the tympanites, diarrhoea, stupor, delirium, &c, increase, a 
liberal blister should be applied to the epigastrium, for the purpose of ar- 
resting the intestinal ulceration, and subduing the inflammation upon 
which it doubtless depends. 

The sulphate of quinine, in two or three grain doses should be given, 
in mucilage of gum arabic, every six hours, to arrest the sinking ten- 
dency, and to prevent congestion, and especially of the alimentary 
mucous membrane. The crust coffee, one-third or one-half milk, should 
be allowed freely, so that the patient may get from one to two pints of 
milk per day, with considerable nourishment from the bread. This affords 
a pleasant drink, and a reasonable amount of nourishment, and in a very 
suitable form ; without which, the system must sink, for it is on food 
that we live. 

If the diarrhoea is very considerable, two grains of tannin may be 
given every six hours, alternating with the quinine, till it is in a measure 
controlled. As the blister to the epigastrium begins to heal, if the tym- 
panites, diarrhoea, stupor, &c, still continue to considerable extent, a 
blister should be applied to the abdomen, below the umbilicus, and the 
other treatment continued. In some cases, if the sinking tendency be 
considerable, one or two grains of camphor may be given with each dose 
of quinine, as it will add much to its sustaining effects, and often relieves, 
to some extent, the flatulency, which is apt to be troublesome. 

As the blister on the abdomen begins to discharge, the tympanites, and 
other unpleasant typhoid symptoms, will generally entirely subside ; and 
it will generally only require a continuation of the quinine, in two or 
three grain doses, in solution, every six hours, with mucilage, and nou- 
rishment, to conduct the patient on to convalescence and health. If, 
however, the case has been protracted, and the strength of the system 
very much exhausted, arrow-root, cooked in mutton or chicken broth, may 
become necessary ; and when it is, it should be given at meal hours, and 
continued till toast, a poached egg, and other digestible kinds of nourish- 
ing food can be borne. 



128 GENERAL FEVERS. 

To prepare the arrow-root in mutton or chicken broth, dissolve a tea- 
spoonful in two ounces of cold water, and while the broth, prepared in 
the usual way, is boiling, pour the solution of arrow-root into half a pint 
of it, and let it cook for four or five minutes. Of this, the patient may 
be allowed as much as he likes, at regular meal hours, the crust coffee 
and milk being allowed at all hours as a drink. 

In this way, I have generally succeeded in arresting severe or ne- 
glected cases, in from ten to fifteen days ; as convalescence becomes es- 
tablished, diminishing the dose of quinine, usually giving one or two 
grains after each meal, in solution, and with mucilage of gum arabic. 
Or if the quinine becomes unpleasant, I sometimes substitute the fluid 
extract of cinchona, or of columbo, in from one-third of a dram, to 
dram doses, after each meal, during convalescence. 

In some cases, however, in which the patient had been neglected, and 
badly treated, I have found a lingering tympanites, with more or less 
diarrhoea, to continue after the other typhoid, or enteric symptoms have 
subsided. In such cases, I have given the oil of turpentine, in about 
fifteen drop doses, every six hours, alternating with the quinine. It 
appears to relieve flatulence, slightly stimulate, and as an alterative, 
tends, as I believe, to favor the resolution of the gastro-intestinal inflam- 
mation and ulceration. I have generally given it in emulsion, with gum 
arabic, sugar and water, as being the most pleasant, and, also, the best 
adapted to alleviate the inflamed and ulcerated alimentary mucous 
membrane. 

Perforation of the intestines rarely occurs in enteric fever, if it is 
properly treated. But as it* may occur, it is well to remember, that if it 
does, and the passage is sufficiently large to let through the contents 
of the intestines, the patient may suddenly scream, or groan with pain, 
in some part of the abdomen. In the only case of this kind which has 
fallen under my observation, every breath was a groan, the countenance 
grew pale, the pulse weak and fluttering, warm drinks produced an in- 
tense feeling of heat in the abdomen, the powers of life gradually yielded, 
and the patient died in about twenty hours after the perforation oc- 
curred. Should symptoms of perforation occur, the case should not be 
abandoned, the indications should be met as best they may be, bv warm 
fomentations to the abdomen, the free administration of wine whey, &c. ; 
but my firm convictions are that such cases seldom, if ever, recover. 

Thus I have completed what I had to say on the subject of enteric 
continued fever ; and while I would confidently urge the treatment which 
I have suggested, modified, of course, to fulfill the indications which arise 
in each particular case, I would as earnestly advise to abstain as carefully 
from the administration of the least thing which is not clearly indicated, 
and imperatively demanded. 

During convalescence from enteric continued fever, no crude indiges- 
tible articles of food should be indulged in. The whole surface of the 
body may be washed with warm rain water, sufficiently often, to keep the 
skin clean, as it should be, in fact, during the prevalence of the disease. 
This is of importance, not only to the patient, but also for the attend- 
ants ; for though I do not believe that enteric fever is directly contagious, 
I am confident, as I have already stated, that the system may, in enteric 



TYPHUS CONTINUED FEVER. 129 

fever, generate a virus, which will produce genuine typhus fever, and 
probably act, as a strong predisposing cause, of enteric continued fever. 

SECTION V.— TYPHUS CONTINUED FEVER. 

By typhus fever I mean that variety of continued fever which has 
been treated of uncler the names of spotted fever, putrid fever, camp 
fever, ship fever, jail fever, hospital fever, Spc, 

The term typhus, from r«$o$, stupor, is indicative, perhaps, of the most 
prominent symptom essential to this febrile affection. But if a suitable 
term could be agreed upon, which would indicate more directly the real 
pathology of the disease, it might be preferable. Of the terms suggested, 
that of "putrid fever," perhaps, might be the least objectionable if it 
were more generally employed. I shall, therefore, use the term typhus 
fever and putrid fever as synonymous, though the terms may indicate 
conditions not essentially similar or identical. 

I believe that a putrid condition of the fluids and solids of the system 
invariably prevail, to a greater or less degree, in all cases of genuine 
typhus, and, in fact, that a putrid tendency is an essential characteristic 
of the disease under whatever form and in whatever locality it may 
prevail. 

Symptoms. — Now, keeping in mind the putrid character or tendency 
of this febrile affection, the symptoms developed during the different 
stages are just what might be expected. And especially are they so, 
when we take into account the fact, that the contagion or morbid poison 
which produces it. acts directly upon the blood, and, through the blood, 
upon the brain and nervous system, and, in fact, upon all the fluids and 
solid tissues of the body. 

During the forming stage, while the blood is gradually becoming 
changed, and the brain and nervous system, as well as all the solid 
tissues, are becoming more or less affected, there is languor, loss of 
appetite, an uneasiness at the pit of the stomach, slight giddiness, and 
nausea, a pale, shrunken countenance, dull, heavy eyes, tremor of the 
hands, a feeling of weariness, debility, and disinclination to mental or 
corporeal action. 

These premonitory symptoms may continue from two or three to five 
or six days, at which time the general derangement of the system has 
become sufficient to develop other and more decided symptoms, such as 
slight chills, alternating with flushes of heat, entire loss of appetite, 
pains in the back, loins, and lower extremities, nausea, and sometimes 
vomiting ; a frequent and feeble pulse ; the tongue becomes coated with 
a white fur, there is a confused heavy sensation in the head, and in- 
creased disinclination to mental and physical exertion. 

The patient takes his bed generally during this stage of invasion. It 
may last from eight to fourteen hours, during which time there may be 
frequent chills, with slight flushes of heat, or there may be a continued 
state of coldness, more or less severe, with great heaviness in the back, 
and confusion or a lost feeling in the head. 

Gradually, as this cold or congestive state continues, the brain, spinal 
cord, and nervous system become irritable ; the impression passes through 
y 



130 GENERAL FEVERS. 

tlie sympathetic nerves to the heart and arteries ; the circulation is 
aroused ; the face becomes flushed; the heat of the body accumulates or 
increases ; the pulse rises in strength and fullness ; the skin becomes 
dry ; there is thirst ; the tongue becomes more furred and slimy ; the 
bowels are constipated ; the mind more confused ; the patient becomes 
fretful and restless ; there is an anxious expression of the countenance ; 
the urine is small in quantity and of a reddish color ; the head feels 
heavy and confused ; and generally, during the first two or three days 
of this stage of reaction, occasional manifestations of delirium occur 
during the night. 

About the second or third day of the reaction, there are frequently 
slight catarrhal symptoms, such as injected eyes, slight soreness of the 
throat, painful deglutition, slight difficulty of breathing, and occasionally 
a slight cough. There is, also, frequently some tenderness in the right 
hypochondriac region, and more or less pain through the back, loins, 
and lower extremities, and, in fact, a general soreness felt through the 
whole body. 

The heat of the surface accumulates, as there is little perspiration, 
producing that peculiar character of heat called color mordax, imparting 
to the hand a stinging sensation, which may continue even after it is 
removed from contact with the affected body. The temperature of the 
surface by the thermometer, according to Professor Wood,* varies from 
100° to 109° F. at the height of this disease. 

About the close of the third day of the stage of excitement or reac- 
tion, there is generally considerable giddiness and sensorial obtuseness, 
the patient even thus early appearing as if under the influence of some 
narcotic. The cerebral functions now become more and more disturbed ; 
the pulse becomes frequent and feeble ; the respiration hurried ; the 
hearing obtuse ; delirium more frequent and considerable ; and the general 
torpor increases. 

About the fourth day of the febrile reaction, an eruption makes its ap- 
pearance, consisting of small red spots, varying from the merest speck 
to spots one-fourth or half an inch in diameter. This eruption generally 
occurs upon the neck, breast, and, sometimes, appearing very much like 
measles, extends over the whole body. The spots are but very slightly 
raised, and vary in color from a bright red to nearly black, the darker 
color appearing usually in the more malignant cases. 

These spots, though often numerous, are sometimes very few or en- 
tirely wanting. And though they generally appear about the fourth 
day of the fever, they may appear any time from the third to the fifteenth 
day of the febrile reaction. This eruption is sometimes accompanied 
with small vesicles or sudamina, and, in some rare cases, the sudamina 
appear without the eruption. The eruption or the sudamina may con- 
tinue from four to ten or twelve days, or they may continue till conva- 
lescence is established. 

One of the most prominent peculiarities of typhus is the almost insur- 
mountable aversion to corporeal and intellectual exertion, which is mani- 
fested through nearly the whole course of the disease. The patient 

* Wood's Practice, vol. i., page 366. 



TYPHUS CONTINUED FEVER. 131 

moves slowly and with reluctance, and answers questions with hesitation 
or fails to answer them at all. 

The stage of febrile excitement usually continues about six or seven 
days, when the system, apparently exhausted, sinks into a state of col- 
lapse. This collapse may, however, occur any time after the chill or 
stage of invasion, sometimes even continuing without any marked febrile 
reaction after the chilly stage, the shock to the brain and nervous system 
being so great that the circulation does not even rally. When, however, 
as generally happens, the febrile excitement subsides, after it has con- 
tinued from four to eight days, the occurrence of collapse is marked or 
manifested by the subsidence of the previous inflammatory symptoms 
and the supervention of great prostration. 

The pulse becomes feeble and generally more frequent, the tongue 
becomes brown and eventually black, the teeth and prolabia become 
incrusted with dark sordes, there is a stunned, confused, and deranged 
state of the sensorial functions, with more or less constant muttering 
delirium, and generally total indifference to surrounding objects. There 
is difficulty of hearing, twitching of the muscles of the face, difficulty of 
protruding the tongue, recumbence on the back, and gradual sliding 
towards the foot of the bed, from deficient muscular power, that peculiar 
biting heat of the skin called color mordaz, and finally, in violent cases, 
dark spots on the surface, hiccough, and generally a more or less tym- 
panitic state of the abdomen. 

During the collapse the urine is generally copious, and often foams 
when voided into a vessel ; and, in some cases, there is a tendency to a 
diarrhoea in the latter stages, the discharges being watery, and highly 
offensive. Towards the termination of the stage of collapse, when it 
tends to a fatal termination, coma more or less complete is seldom absent, 
from which, however, the patient may generally be roused for a few 
moments. The state of collapse usually continues from seven to nine 
days, terminating either in slow convalescence or in death. 

The occurrence of convalescence is announced by the appearance of a 
gentle perspiration, and reduction of the acrid heat of the skin, a moist 
tongue, cleaning along the edges, copious and sedimentous urine, abate- 
ment of the delirium, and in some instances a moderate diarrhoea. The 
phenomena of a favorable crisis may occur any time from the seventh to 
the thirtieth day, but I think, generally, from the fourteenth to the 
twenty-first day ; allowing one week for the forming stage, one for the 
stage of febrile reaction, and one for the stage of collapse. 

The convalescence is generally tedious, as there remains a general 
debility and prostration of the whole system, after the total subsidence 
of the fever. Such are the symptoms of simple typhus continued fever, 
in its ordinary course, varying, of course, in degree, from the mildest 
cases, which continue only for a few days, and require little or no treat- 
ment, to the most malignant cases, passing through the different stages, 
and hastening to a fatal termination, or else to a favorable crisis and 
slow convalescence. 

Varieties. — Typhus is liable to assume either an inflammatory or con- 
gestive character, both of which it becomes necessary to consider, as the 
different morbid conditions require correspondingly different modes of 



132 GENERAL FEVERS. 

treatment. During the continuance of typhus local inflammations are 
liable to occur, of the brain, lungs, alimentary mucous membrane, of the 
liver, and peritoneum ; and of these, the brain, lungs, and alimentary 
mucous membrane are the most frequent. When inflammation does 
occur, it constitutes the inflammatory variety of typhus. 

Generally, in these cases, the phlegmasial symptoms do not occur 
until the second or third day of the stage of excitement, but sometimes 
earlier. If the brain becomes inflamed there is deep and pulsating pain 
in the head, flushed countenance, throbbing carotids, redness and sensi- 
bility of the eyes, irritability of temper, pains in the extremities, irre- 
gular respiration, continued wakefulness, early and uninterrupted deli- 
rium, a bloodshot appearance of the eyes, contracted pupils, intolerance 
of light, agitated countenance, continued moaning, and coma. 

When the lungs become inflamed the symptoms of pneumonia are 
added to those of typhus, only in the pneumonia of typhus the sputa 
are generally of a rusty appearance, from the very commencement of the 
inflammation. 

The symptoms of enteric inflammation, when it occurs, are tension 
and tenderness of the abdomen, an anxious and disturbed countenance, 
a small, quick, and frequent pulse, recumbence on the back, vomiting, 
desire for cool drinks, difficult deglutition, and great prostration of 
strength. In such cases, however, the patient seldom complains of 
much pain in the abdomen, and there is no very great degree of ten- 
derness, unless firm pressure be made, when slight suffering will gene- 
rally be expressed by the appearance of the countenance. 

In the congestive variety of typhus there is a want of reaction after 
the stage of oppression, or cold stage, the system remaining in a con- 
gested and oppressed condition during the whole course of the disease. 
The vital powers, in such cases, are overwhelmed, and the patient appears 
to sink, progressively, from the moment the disease commences till the 
vital action ceases altogether. 

In aggravated cases of this kind of putrid fever, there is from the 
very beginning extreme debility, with deep-seated pain in the head, ver- 
tigo, the face is pale, the respiration is oppressed and slow, the pulse is 
small, feeble, and variable, the skin relaxed and damp, and may be below 
the natural temperature, the countenance confused and anxious, the eyes 
watery and red, the bowels torpid at first, but in the latter period of the 
disease there may be a diarrhoea. The tongue is at first pale and slimy, 
but it becomes rough, brown, and sometimes nearly black, as the disease 
progresses. Towards the close, colliquative hemorrhages and involuntary 
stools generally occur. Sometimes coma is among the first symptoms, 
and continues to the end of the disease, and I have not unfrequently 
seen a complete state of insensibility to supervene very soon after the 
attack of the disease. 

Diagnosis. — The diagnosis of typhus, or putrid continued fever, is not 
usually attended with any great difficulty, if all the symptoms are taken 
into the account. Typhus may generally be distinguished from enteric 
or typhoid fever, by careful attention to the following diagnostic 
symptoms. 

Typhus fever is generally less insidious in its approach and attack 



TYPHUS CONTINUED FEVER. 133 

than typhoid or enteric continued fever, the bowels in typhus also being 
generally more or less constipated, while in enteric fever there is often 
a diarrhoea from the commencement. In typhus, the sensorial functions 
are earlier and more invariably disturbed, and the muscular prostration 
is greater than is common in typhoid or enteric fever. 

Mental depression, a sullen gloom of the countenance, and disinclina- 
tion to mental and corporeal exertion, are remarkably characteristic of 
typhus, and not so conspicuously present in enteric fever. In typhus, 
the patient usually answers questions with reluctance, while in typhoid 
fever, in most cases, questions are answered more readily. The eruption 
in typhus generally makes its appearance earlier, is of a darker color, is 
more abundant, and comes out more generally over the whole body than 
is common in enteric fever, and besides, in typhus, sudamina are less 
frequently seen than in enteric fever. 

In typhus fever, there is generally a less tympanitic state of the abdo- 
men than in enteric fever, and the average duration of typhus is pro- 
bably only about tw -thirds that of enteric continued fever, typhus also 
being marked by the three conspicuous stages of invasion, reaction and 
collapse, which do not mark enteric fever. Typhus fever is very liable 
to attack old people, while enteric fever more frequently attacks the 
young. Typhus fever is also highly contagious, while enteric fever is 
scarcely if at all so ; it is probable, however, as I have before intimated, 
that the system in enteric fever may generate a virus, or morbid poison, 
which will produce typhus, and very strongly predispose to enteric fever. 

It is a fact that in incipient typhus it may sometimes be difficult to 
distinguish typhus from some cases of simple continued fevers, as well 
as enteric ; but by taking into the account the diagnostic symptoms which 
I have enumerated, and by keeping in mind the prevailing epidemic and 
endemic tendencies, the acute observer need seldom if ever be mistaken 
in the diagnosis of typhus fever. 

Anatomical Characters. — The post-mortem appearances, in simple 
typhus, if we except the appearance of the blood, are not of a degree of 
uniformity that would justify us in considering the disease one of a local 
character. In fact, if the patient die early, there is often found no local 
morbid lesion to which to attribute the dissolution. And in the inflam- 
matory variety of typhus, the morbid lesions of the parts inflamed are 
the result of an accidental, not an essential complication of typhus, as we 
have already seen ; and the same is also true of the local lesions which 
may be found in congestive typhus. 

But the blood, I believe, is always in pure typhus found in a changed, 
or abnormal state. Prof. Wood says,* " after death it is found in the 
veins black, liquid, sometimes resembling molasses, and occasionally 
mixed with oily globules." And besides, it is a well-known fact that 
blood drawn in the latter stages of typhus coagulates imperfectly, and 
sometimes is almost black. So far, then, as the morbid appearances are 
indicative, the blood is emphatically the seat of typhus fever, as it inva- 
riably presents a changed appearance, and as every other morbid ap- 
pearance, or changed condition, is more or less accidental. 

Causes. — Typhus fever may be produced by impurities arising from 
* Wood's Practice, vol. 1, p. 370. 



134 GENERAL FEVERS. 

crowded apartments, in which filth, and especially animal secretions and 
exhalations are an ingredient, constituting idio-miasmata ; or from a 
morbid poison, generated in the system while laboring under typhus, and 
probably also sometimes in enteric fever, and also from that sum of all 
human imprudence, epidemic influence. 

It is probable that the cause may be one, however, in the three cases, 
for in crowded apartments in which filth and animal secretions and ex- 
halations are an ingredient, it is probable that its decomposition may 
produce a morbid poison, identical with that generated in, and emanating 
from, the bodies of patients suffering from typhus fever. And further, 
as epidemic influences are probably the direct result of the combined in- 
fluence of the sum total of every species of filth and uncleanness, result- 
ing from human degradation and imprudence, it is more than probable 
that when typhus is so produced, it is in consequence of decomposed ani- 
mal matters, as in other cases. 

It is rational to conclude, then, that idio-miasmata, or a deleterious 
morbid poison, or effluvia, originating from the decomposition of matter, 
derived from the human body, or emanating from the body of patients 
suffering from typhus, and perhaps from enteric fever, is the invariable 
cause of typhus continued fever. 

That typhus is strictly a contagious disease, I have not a reasonable 
doubt, and yet it does not, except in powerful epidemic influences, ap- 
pear to be conveyed to any very considerable distance by the air, at least 
in a sufficiently concentrated state to produce the disease. But the 
typhus contagion may become attached to various articles of clothing, 
and thus be conveyed to great distances, and also retain its power of in- 
fecting for a long time, probably for several months. 

Nature. — Having now inquired into the symptoms, cause, &c, of 
typhus, let us inquire into its nature, if, in fact, it needs an inquiry ; for 
it appears to me there remains little room for doubt. It is probable that 
idio-miasmata, or the morbid poison of typhus, enters the blood through 
the mouth, lungs, and perhaps the absorbents of the skin ; and that once 
introduced into the circulation, it unites chemically with the blood, ma- 
terially decomposing or changing it ; thus not only acting upon the inner 
surface of the circulatory system, but also rendering the blood itself a 
poison, not only to the circulatory system, but also to the brain and 
nervous system, and, in fact, to every tissue of the body to which the 
blood is sent. 

Now the blood, in this state, either by directly poisoning, or by a 
negative property failing to supply or furnish the brain sufficient vital 
power, disqualifies the brain for generating sufficient nervous influence 
to keep up a healthy action of the different organs of the body. As a 
consequence of all this, the powers of life are more or less prostrated 
even during the forming stage ; the circulation yielding at the approach 
of the chill. 

During the chill, the cerebro-spinal system becomes irritated, and as a 
consequence, an irritated influence is sent through the cerebro-spinal to 
the ganglionic nerves ; and there is set up an irritated reaction of the 
circulatory system, which continues through the second stage, or that of 
febrile reaction. This irritated reaction is kept up till the system be- 



TYPHUS CONTINUED FEVER. 135 

comes too much exhausted to sustain even that ; and so, after a few days, 
perhaps a week, there comes a collapse, through which the patient may- 
pass on in another week to dissolution ; or else, with proper aid, to per- 
manent but slow convalescence. 

In those cases in which local inflammations occur, whether of the 
brain, lungs, liver, or bowels, it is evidently accidental ; of a passive 
character ; and results from the general prostration, and also the de- 
ranged condition of the fluids and solid tissues of the system. 

In congestive typhus so great is the prostration of the system, in some 
instances, that there is really no reaction of even an irritated character, 
the brain and nervous system being apparently incompetent to keep up 
the circulation, or carry on the functions of the body ; and so death oc- 
curs without any reaction or local inflammation, at least so far as can be 
discovered by post-mortem examination. And finally, another strong 
reason why typhus should be regarded as a disease of the blood, involv- 
ing a changed or decomposed state of that fluid, is the very general 
hemorrhagic tendency in this disease, which is not found to prevail to 
so great an extent in fevers produced by other febrific agents. 

Prognosis. — The prognosis in typhus depends very much upon the 
habits and consequent predisposition of the patient, and also upon the 
prevailing epidemic influence. In simple typhus, however, the prognosis 
may be regarded as rather favorable, especially if no complications arise. 

But in inflammatory and congestive typhus the danger is greater, in 
proportion to the parts involved, or the severity of the congestion. A 
moderate diarrhoea, occurring early in typhus, or a slight bleeding 
from the nose, the sixth or seventh day, are favorable indications. The 
most certain sign, however, is to be found in the sensorial functions, for 
if these are but slightly disturbed during the collapse, it indicates a less 
changed state of the blood, in consequence of which the case will proba- 
bly terminate favorably. 

The unfavorable symptoms are violent delirium during the stage of 
excitement, blindness, involuntary flow of tears, paralysis of the tongue, 
a frequent small, irregular pulse, distortion of the muscles of the face, 
tenderness of the abdomen, continued motion of the hands, dysenteric 
stools, aphthae in the mouth, colliquative hemorrhage, &c. 

Treatment. — Taking into account the deviation from the standard of 
health in putrid or typhus fever, the indications become very plain, not 
only in the simple, but also in the inflammatory and congestive varieties, 
and if the indications be promptly fulfilled during the early stages, I 
believe many cases may be arrested or, at least, very much cut short. 
We have seen that there are three prominent varieties of typhus : the 
simple, the inflammatory and the congestive ; all of which require modi- 
fications in the treatment. 

When called to a case of typhus in the early stage, before the febrile 
reaction is set up, we find the patient prostrated, chilly and irritable, 
generally with pain in the head, back and limbs, all of which is pro- 
duced by debility, and especially of the cerebro-spinal and nervous 
system, involving of course the circulatory system, the blood having 
ceased to flow freely to the extremities. 

Now to arrest the chilliness, equalize the circulation, promote perspi- 



136 GENERAL FEVERS. 

ration, and restore as far as may be the functions of the body, the feet 
should be placed in "warm water, the back should be rubbed with a strong 
decoction of capsicum in vinegar, and warm sage tea allowed as a drink. 
This will do much to arrest the chilliness, equalize the circulation, and 
to rally the sinking powers of the system, and will sometimes send forth 
a gentle perspiration. 

If there is much nausea, or a very bad taste in the mouth, an emetic 
of ipecac may sometimes be given with advantage at first, and then fol- 
lowed by a cathartic. After the emetic, or at first when no emetic is 
indicated, a cathartic is generally required to affect slightly the gastric 
and hepatic functions, and to carry from the alimentary canal any accu- 
mulation that might become a source of irritation. What I have 
generally found to do best in such cases are two or three blue pills, fol- 
lowed in six hours by half an ounce of castor oil, and repeated if neces- 
sary. Or, if there is a strong tendency to the brain, and constipation, 
ten grains of calomel, with twenty grains of rhubarb, may be adminis- 
tered in half an ounce of castor oil, and the oil repeated if necessary. 

A liberal sinapism should be applied over the stomach and bowels, and 
repeated morning and evening, as well as the warm foot bath, and stimu- 
lating application to the spine, if the exercise can be borne without 
worrying the patient. By the warm foot bath we lessen the tendency to 
the brain and promote perspiration ; by the stimulating friction along 
the back the circulation is more or less equalized, while the sinapisms 
to the abdomen will guard the alimentary canal and other abdominal 
viscera, and by a general stimulating effect help sustain the sinking 
powers of the system. 

After the operation of a cathartic the sulphate of quina, or quinine,* 
to restore the tone of the system, to equalize the circulation, and also to 
counteract the change going on in the blood, is evidently indicated, as 
well as a mild anodyne and diaphoretic. In such cases I generally use 
quinine and Dover's powder combined, of each three or four grains 
every four or six hours, and allow crust-coffee, one-third or one-half 
milk, to keep up the strength, and as soon as the stomach will bear it, 
a little toast, or a poached egg, at regular meal hours. 

In this way, I believe, a large majority of the cases of typhus that 
are attended to early may be arrested and convalescing in five or six 
days, especially if the patients can have the benefit of good fresh air, 
clean clothing and good nursing. I suspect that the quinine, besides its 
general tonic effect, operates to arrest or lessen the morbid change going 
on in the blood, and probably, in some degree, to destroy or neutralize 
the contagious poison that has entered the blood, and is producing the 
disease. But if from neglect, or bad treatment at first, the disease has 
become more seated and complicated, and the febrific agent has had time 
to produce its worst effects upon the blood, then this course of treat- 
ment, though it may not arrest the disease, will always lessen its vio- 
lence, and render it less tedious and protracted. At least such has been 
the result of my observation. 

If in such cases the stage of excitement has passed by, and the stage 

* I prefer the term quinine to that of quina, and shall therefore generally make use of 
it, as T have done. 






TYPHUS CONTINUED FEVER. 137 

of collapse is approaching, the Dover's powder should be discontinued, 
and the quinine continued with camphor. A convenient mode of 
administering them is to rub thirty-two grains of camphor, and an 
equal quantity of quinine, with a scruple of dry prepared chalk, and 
then add two ounces of water and mix carefully. Of this a teaspoon- 
ful, containing two grains of each, may be given every four or six hours. 

A blister should be applied over the stomach, and later over the 
bowels if necessary, in most cases that are not arrested by mild means 
in the early stages, for by it we secure the safety of the mucous mem- 
brane of the alimentary canal, and other abdominal viscera. Even if 
the abdominal viscera are not involved especially, a blister to the epi- 
gastrium has often a salutary effect, allaying the most alarming symp- 
toms of cerebral affections. In cases of that kind in which there was 
delirium, picking at the bed clothes, and other symptoms of an alarming 
character, I have known them speedily arrested by a blister to the epi- 
gastrium. 

After blistering over the stomach, and bowels if necessary, if the 
symptoms continue alarming a blister may be applied to the back of the 
neck to allay any local irritation there may be in the brain. After the 
first cathartic in simple typhus, the bowels should be moved once in 
every twenty-four hours by castor oil, or by an injection of a pint of 
milk and water, in which is dissolved a tablespoonful of salt, lard and 
molasses. 

The strength should be sustained by toast water, or crust-coffee one- 
half milk, taken freely as a drink, at all hours ; and during the collapse 
arrow root may be freely allowed, and in some cases of great prostration 
wine whey may become necessary. During the stage of febrile excite- 
ment, if the heat of the surface be intense, the skin may be sponged 
with moderately cool water once every twenty-four hours. This, how- 
ever, should never be done when the skin is cool or moist, moderately 
warm water being alone suitable in such a state. 

In inflammatory typhus the early treatment should be the same, only 
an emetic should not, I think, generally be given, especially if the brain 
be involved, as the vomiting might increase the local inflammation. If 
the brain be the seat of the inflammation, a cathartic of calomel in 
castor oil should be administered, the warm foot bath, and stimulating 
friction along the back, should be used ; but instead of the Dover's 
powder and quinine, the antimonial or James's powder should be sub- 
stituted, in three or four grain doses every four hours, as they lessen the 
tendency to the brain, while the Dover's would rather increase it, and 
the quinine might act unfavorably. 

A blister should be applied to the back of the neck, and if the inflam- 
mation continues after the blister has produced its effects, two grains of 
calomel may be given with each dose of the antimonial powder, and 
continued for twenty-four or thirty-six hours, and then half an ounce of 
castor oil administered, if the calomel has not moved the bowels. In 
such cases, immediately on the approach of collapse, I would give qui- 
nine and camphor with the antimonial, or James's powder. Three 
grains of quinine and two of camphor may be given with the four grains 
of James's powder every four hours, and continued through the state of 
collapse, or as long as the condition may require. 



138 GENERAL FEVERS. 

The strength should be sustained by toast-water, at first, and dur- 
ing the collapse, arrow-root cooked in broth, wine whey, and as soon as 
it may be borne, a poached egg, rice, toast, &c, may be allowed at 
meal hours. 

In cases where there is inflammation of the alimentary mucous mem- 
brane, the early treatment should be in every respect as in the simple 
variety, only a cathartic of an active character should not be given. 
Twenty grains of rhubarb, with ten grains of the hydg. cum creta, may 
be mixed with half an ounce of castor oil, and administered ; or if the 
mercurial may be contra-indicated, half a drachm of the fluid extract of 
the leptandra virginica may be given instead, and repeated in six hours 
if necessary ; or what might be more convenient, one or two grains of 
the leptandrin, its most concentrated preparation. 

The quinine and Dover's powder may be given, as in the simple 
variety, but all the medicines which become necessary in such cases, 
should be administered in mucilage of gum arabic, and arrowroot cooked 
in milk and water allowed for food. This may be prepared by dissolving 
a teaspoonful of arrow-root in two ounces of cold water, and stirring it 
into half a pint of milk and water of each equal parts, raised to the boil- 
ing point ; after which it should be boiled four or five minutes, and sea- 
soned to suit the taste of the patient. 

In cases in which the lungs are inflamed, after the early treatment 
suggested for the simple variety, I would give quinine, Dover's and 
James's powders combined, in doses of four grains each, every four or 
six hours, adding a grain of calomel to each dose, for the first day or two 
if necessary. A blister should be applied over the inflamed lung, and 
mucilages freely allowed. 

In congestive typhus the same early treatment should be applied, and 
the patient immediately put upon the sulphate of quinine, in six or eight 
grain doses, every four or six hours, with four grains of Dover's during 
the first, and two grains of camphor during the latter stages of the dis- 
ease. The strength should be sustained from the first, and during the 
whole course of the disease, by broths, beef essence and wine whey, if 
necessary, and under such treatment the most foreboding cases may 
sometimes recover. Thus we have the principles which are to guide in 
the treatment of typhus continued fever, requiring, however, to be modi- 
fied, to fulfill the indications which arise in each particular case. 

SECTION VI.— YELLOW FEVER. 

By yellow fever, I mean that variety of febrile affection, regarded by 
some as remittent, and by others as continued fever, occurring in warm 
climates, and characterized by a peculiar expression of the countenance, 
a yellow skin, and by the ejection from the stomach of a dark fluid, 
which has been called black vomit. 

This disease seldom prevails, I believe, at a distance of more than 40° 
north or south of the Equator ; being endemic in regions north and 
south of the Equator to about the 30° or 32°, and occasionally epidemic 
from that to the 40° or 42°, but by no means equally distributed in 
those regions. 

This disease generally prevails mostly in large towns, situated upon 



YELLOW FEVER. 139 

the sea-coast, or along rivers emptying into the sea, where large num- 
bers of human beings are congregated ; but seldom prevails, I believe, 
to any great extent in a scattered population. There, it is thought, that 
a temperature of about 80° F. continued for nearly, or quite three 
months, is requisite for the appearance or prevalence of yellow fever ; 
though it is probable that sporadic cases may occur where the tempera- 
ture never remains to that point for half that time. 

Yellow fever generally makes its appearance in localities where it is 
endemic or epidemic in the latter part of summer and in autumn, but 
invariably receives a check on the appearance of frosts, and very soon 
after entirely disappears. 

This disease always has some symptoms or features which are uniform 
or similar, and yet there is scarcely any variety of disease which afflicts 
the human family, which, in different localities, or in the same locality 
in different epidemics, presents such varieties of symptoms and severity. 
And even in the same epidemic, the range of symptoms and severity are 
very great, varying from the mildest cases, little worse than simple 
bilious remittent fever, to the congestive, in which vitality is smitten 
down, as it were, at the very moment of attack, and the patient swept 
away in two or three days, or perhaps as many hours. 

To give the history, with all the peculiarities and varieties of yellow 
fever, would require a volume. I shall, therefore, not attempt to do 
more than to give the general character of the disease, as it most gene- 
rally prevails, leaving the reader to fill up the history and multiplied 
varieties, as it occurs in different localities, by the accounts furnished by 
eminent physicians residing in each locality where the disease presents 
its peculiarities. With these considerations, let us proceed to inquire 
into the symptoms of yellow fever, as it generally prevails, from a cor- 
rect understanding of which all its varieties may be readily appreciated 
and understood. 

Symptoms. — In some instances, yellow fever makes its attack with 
scarcely no premonitory symptoms; but generally there are pains in the 
back and extremities, and sometimes in the head ; the patient feels more 
or less indisposed for an indefinite time, during which there is a gradual 
sinking of all the powers of life, involving more or less derangement of 
all the functions of the body. After these symptoms have continued 
for an indefinite time, when they do appear, or at the very first when 
they are not noticed, there is generally slight chilliness, though in many 
cases no regular chill, and very soon febrile reaction is set up, develop- 
ing the following symptoms. There is restlessness, thirst, a hot and 
dry skin, the respiration is hurried, the eyes red and watery, the face 
flushed, the tongue becomes covered with a white fur, there is more or 
less soreness of the fauces, and difficulty experienced in swallowing, and 
sometimes nausea and vomiting immediately on the setting up of febrile 
action. 

Generally, in the course of twenty-four hours from the chilliness, or 
time of febrile reaction, the patient complains of great oppression, 
weight, and tension in the epigastrium ; there is more or less tenderness 
on pressure, and vomiting, especially of everything taken into the 
stomach ; the vomiting being often violent and distressing from the flatu- 
lence which is apt to attend. 



140 GENERAL FEVERS. 

The patient complains of great gastric heat, and therefore has an 
intense thirst for cold drinks. The bowels are generally constipated, 
the discharges being also of an unhealthy appearance, and very offen- 
sive. There is pain in the forehead, eyes, and sometimes in one side of 
the head, of a violent and most distressing character, and is only sur- 
passed by the excruciating pains in the back and extremities, which 
often continue during the period of febrile excitement. 

There is more or less mental disturbance at this stage, the patient 
being exceedingly restless, and more or less delirious, and often wild 
and furious in his movements ; but there may be instead, in congestive 
cases, drowsiness, stupor, coma, &c. 

This stage of febrile reaction may continue, in violent cases, but a few 
hours ; but in mild cases it is sometimes prolonged to three or four days ; 
but the average duration of this febrile stage may be set down at two 
days, being evidently an irritated reaction of the circulatory system, 
holding out for a longer or shorter time, according to the violence of 
the attack, and the natural powers of the system. 

As the system becomes exhausted, this irritated febrile action subsides 
more or less, the skin becoming cool and soft, the pulse more natural, 
the respiration less hurried, the stomach more quiet, the pain in the 
back and head subsides, and the general distress of body and disturb- 
ance of mind is followed by comparative ease, and more or less cheer- 
fulness. 

In mild cases, this subsidence of the fever may be the commencement 
of convalescence, but not so in severe malignant or congestive cases, for 
then it only indicates inability on the part of the system to keep up even 
an irritated action of the circulatory system. The tenderness of the 
epigastrium is rather increased. In place of the redness of the eyes 
and face, they have a yellow or orange-colored appearance, which gra- 
dually extends itself till it covers the whole body. The urine becomes 
yellow, the pulse much slower than in health, and in severe cases, there 
is sometimes a little drowsiness or stupor. 

This period of abatement may last for twenty-four hours, when there 
comes on the stage of debility, prostration or collapse, during which the 
pulse becomes feeble, quick and irregular ; the skin becomes more yel- 
low ; the circulation becomes languid, especially in the capillaries ; the 
extremities become purple ; the tongue becomes brown and dry, or red- 
dish ; sordes gather about the teeth ; the stomach becomes irritable, 
and ejects a darkish liquid, containing darker flakes which finally 
become black ; the blood recedes from the extreme vessels ; the urine 
may appear natural or be nearly suppressed ; blood may ooze from the 
gums, or from the mucous membranes in different parts of the body, or 
it may be thrown from the stomach, or pass from the bowels, or with 
the urine ; and it is not unfrequently extravasated under the skin, in 
different parts of the surface of the body. 

By degrees the pulse becomes almost imperceptible at the wrist, there 
is frequent sighing, and hiccough, the skin becomes cold and clammy, 
large quantities of blackish matter are ejected from the stomach, and dis- 
charged from the bowels, an offensive odour exhales from the body, the 
eyes are sunken, there is a low muttering delirium, the countenance 



YELLOW FEVER. 141 

becomes cadaverous, and finally the patient dies, either in violent con- 
vulsions, or else passes off rather quietly. In some cases, however, the 
patient, instead of passing off thus rapidly, may linger for perhaps two 
or three vreeks in a typhoid state, and then sink down, or else slowly 
convalesce. 

When the patient does recover, either from a violent and rapid course, 
or from a typhoid and lingering run of fever, the convalescence is slow 
and tedious. — Thus we have the general symptoms and course of yellow 
fever, exhibiting three distinct stages : the first, that of primary febrile 
action, which may generally continue for two days ; the second, that of 
abatement, lasting about one day ; and, finally, the stage of collapse, 
which may generally last two days in rapidly fatal cases ; or the patient 
may pass into a slow typhoid state ; or there may instead be slow con- 
valescence. 

In some cases, there is no febrile reaction, at least that is perceptible, 
the patient being struck down as it were from the first, in a congestive 
state ; or if there is a slight effort at reaction, it soon gives way, and the 
system remains prostrated, and in a congested state, the stomach eject- 
ing large quantities of black, or bloody matter, the skin becoming dark 
yellow, and the patient rapidly sinking with hemorrhages, and all the 
more alarming symptoms of this truly malignant disease. It has been 
noticed by some, that there is an offensive breath in these more malig- 
nant cases, and in some epidemics, a rash has made its appearance upon 
the face, neck, and some parts of the body, during the first stage of the 
disease. 

It will be noticed, that the most strikingly peculiar, or characteristic 
symptoms of yellow fever, are the rapid, irregular, and jerking, or else 
slow and feeble pulse, a reddish appearance of the upper part of the 
face, and bloodshot appearance of the eyes, the yellow appearance of 
the skin, coming on by the third or fourth day ; and, finally, the black 
vomit, which makes its appearance generally during the second or third 
stage of the disease. 

In relation to the exact nature and composition of black vomit, there 
has been some doubt ; animalculae and microscopic fungi have, in some 
cases, been detected in it ; but its principal ingredients have been found 
to be disintegrated blood. It is, therefore, rendered probable, that it 
results from, or is composed of, dissolved blood ; the clear liquid being 
the serum, and the insoluble part, the coagulable matter of the blood. 

Diagnosis. — In forming a diagnosis in yellow fever, it is necessarv to 
remember its most prominent characteristic symptoms, the rapid *and 
feeble, or slow and irregular pulse, the red appearance of the eyes and 
face, and the black vomit, as well as the severe, and often excruciating 
pains in the back and lower extremities. These symptoms, together 
with the fact of the prevalence of the disease, and the peculiar symp- 
toms which are developed during the febrile stage, the abatement and 
the stage of collapse, will generally enable the acute observer to form a 
correct diagnosis in most cases of yellow fever. 

Anatomical characters. — The dead body, according to Professor Dick- 
son,* presents various morbid appearances, there being generally more 
* Dickson's Elements of Medicine, pp. 273, 274. 



142 GENERAL FEVERS. 

or less " ecchymosis or subcutaneous effusion of blood." The blood is 
also represented as being dark, and frequently incoagulable, " the heart 
as soft and flabby," sometimes undergoing a fatty degeneracy, the lungs 
"being firm, dark, and heavy," exhibiting marks of inflammation or con- 
gestion. "The brain is usually found more or less altered," its mem- 
branes appearing inflamed ; and it has been stated, that in some cases, 
serum has been found in the ventricles. 

The liver, I believe, does not present any very constant appearances, 
it being sometimes "soft and flabby," while in others, it is more or less 
engorged with darkish appearing blood. Professor Dickson states that 
he has often found it " in a natural state, so far as could be judged by 
the naked eye." In six cases examined by him, " one was fawn-colored, 
very characteristic ; a second was fawn-colored on the upper surface, and 
of a deep purple on the lower side, and around the edges ; two were dark 
chocolate-brown, not far from natural, or olive-colored ; the sixth was 
again of coffee and milk hue, being large and heavy." 

The spleen, according to Professor Dickson's observation, is sometimes 
more or less enlarged, and softened ; but often remains nearly or quite 
natural. The stomach he has always found "reddened and injected on 
its inner surface," and " sometimes on its outer surface also;" and, oc- 
casionally, it was found softened, but he never found ulceration of any 
portion of it. 

The mucous membrane of the oesophagus and duodenum, he found in 
a similar condition, and in hemorrhagic cases, he found more or less 
bloody infiltration in every part of the system. Various other morbid 
appearances may sometimes be found on post-mortem examination of 
patients dying of yellow fever ; but none of them, I believe, are of any 
very great uniformity or importance. 

It will be noticed that I have given the observations of Professor 
Dickson on the post-mortem appearances of yellow fever patients. This 
I have been induced to do, from the fact that my position in practice at 
the North, has not allowed me that amount of observation in such cases 
that I could desire. Professor Dickson, who has for many years been a 
practitioner of medicine in Charleston, South Carolina, where yellow 
fever prevails more or less, has had abundant opportunity for observa- 
tion ; and what is more, has been a close observer, not only in such cases, 
but also in every variety of disease coming under his observation. 

It will be seen, by taking a glance at the general anatomical charac- 
ters of yellow fever victims, that the most important morbid appearances 
presented, are the dissolved, or changed appearance of the blood, and 
the congested and inflamed appearance of the mucous membrane of the 
oesophagus, stomach, and duodenum ; the morbid appearances of the 
liver, spleen, brain, &c, though very frequent, appear by no means es- 
sential morbid appearances in such cases. 

Causes. — In relation to the cause of yellow fever there may be some 
room for doubt, but when we take into account the fact that yellow fever 
almost always prevails on ships at sea, upon the sea coast, or upon navi- 
gable rivers emptying into the sea, we have got at least a clue to the 
cause which may produce it. And especially have we, when we remem- 
ber that it almost invariably prevails in these positions, in localities 



YELLOW FEVER. 143 

where a large number of human beings are associated, and where the 
paludal poison prevails to a greater or less extent. 

Now, from the fact that yellow fever prevails where the paludal poison 
is generated, and where a collection of human beings furnish the mate- 
rials for the generation of idio-miasmata, we have a right to infer that 
Jcoino and idio-miasmata combined produce yellow fever. And though 
this position may not admit of positive proof, it appears to me that all 
the circumstances favor this idea. 

It may be asked, if the koino and idio-miasmata, with a temperature 
of 80° F., is all that is requisite, why may not yellow fever prevail away 
from the sea coast and large rivers emptying into the sea, provided there 
be the material for generating the requisite animal poison, and also the 
presence of the paludal poison, as well as a temperature of 80° F. 

This question may be one more easily asked than answered. But it 
should be remembered, that observations long ago made, and confirmed 
by more recent observation, have rendered it quite certain that a min- 
gling of salt water and fresh along the sea coast favors the generation of 
the paludal poison, and also greatly increases its virulence. 

M. Monfalcon mentions some interesting examples illustrating this 
fact.* " The extensive pool of Valdec, in the south of France, is quite 
saline, and only a few rods from it is a large pool of fresh water. Now, 
when the waters of these two pools rise and run into each other, as they 
occasionally do, much sickness soon occurs throughout the adjoining 
parts." "In the vicinity of Lukes, on the south of the Ligurian Appe- 
nines, there is a large marshy plain, accessible to the high tides of the 
ocean. The neighboring districts were almost uninhabitable from the 
pestilential effluvia which emanated from this marsh, until the waters of 
the sea were separated from the sweet water of the marsh, by means of 
sluices and hydraulic works, when it became healthy, and the population 
increased rapidly." f 

Now, if it be a fact that a mingling of salt and fresh water not only 
favors the generation of the marsh miasmata, but also renders it much 
more virulent, may it not account for the fact that yellow fever prevails 
mostly in localities along the sea coast, where there is always more or 
less mingling of salt and fresh water. And if my position be true, that 
this peculiarly virulent paludal poison, with an animal poison, are to- 
gether the cause of yellow fever, then we should suppose it would prevail 
in such localities upon the sea coast as furnish the most mingling of salt 
and fresh water, and also the greatest amount of animal secretions, ex- 
halations, &c, and not in localities, even along the coast, where human 
beings are not assembled, as is really the case. 

This position appears to me also strengthened by the fact, that not 
only a temperature of 80° F. is requisite, but it also requires to be con- 
tinued for two or three months in order to produce yellow fever, which 
would be requisite if the decomposition of vegetable matters were taking 
place at some depth in the water, as it very probably is, the animal filth 
at the same time undergoing the requisite change. 

Another strong reason for supposing that koino and idio-miasmata are, 

* Histoire Medicale des Marais, Paris, 1828. 
f Eberle's Practice, vol. i., p. 53. 



144 GENERAL FEVERS. 

together, the cause of yellow fever, may be found in the post-mortem 
appearances, which answer very well to what we might expect would be 
found, if an animal and virulent paludal poison produced the disease. 
For in the body dead from yellow fever we find the changed or dissolved 
state of the blood, and the general hemorrhagic tendency which we find 
in typhus fever, and also the marks of congestion, irritation, and inflam- 
mation of the alimentary mucous membrane, so common in bilious remit- 
tent fever. 

And finally, the symptoms and course of yellow fever are what we 
might reasonably look for, if koino and idio-miasmata were operating 
upon the system to produce or develop them, the one passing as a foreign 
substance with the blood, and producing its effect upon the brain and 
nervous system, as in bilious remittent and intermittent fevers, and the 
other, or animal poison, uniting chemically with and changing or decom- 
posing the blood as it probably does in producing pure typhus fevers. 
This supposition will also account for the fact that some cases, and even 
some epidemics, partake more of the paludal character, and even run 
into bilious remittent or intermittent fevers, while other cases, or other 
epidemics, partake more markedly of the typhus and hemorrhagic char- 
acter ; in the one case the animal, and in the other the paludal poison 
existing in the greatest degree of concentration. 

This view of the cause of yellow fever also accounts for or settles the 
question as to its being contagious or not, rendering it contagious in 
just so far as it partakes of the nature of typhus, and not contagious in 
just so far as it is paludal; and this accounts for the apparent differences 
in the contagiousness in different cases, and also in different epidemics. 
Those cases and those epidemics partaking most of the typhus character 
being more contagious, while those cases and epidemics of a more paludal 
character being less so. 

Besides all this, it was long ago observed, and I am confident, as I 
have stated elsewhere, that the combination of koino and idio-miasmata, 
acting upon the system, will produce a most malignant variety of febrile 
disease, as I have witnessed in our climate.* And if so, may we not 
suppose that in a hot climate, where there is a mingling of salt and 
fresh water, and also a large collection of people for furnishing animal 
matter for decomposition, that the virulent animal and vegetable mias- 
mata thus generated may produce every possible variety of yellow fever. 

Nature. — Having inquired into the symptoms, anatomical characters, 
cause, &c, of yellow fever, we are prepared to investigate its nature, 
and if we can draw no positive conclusion in relation to its exact nature, 
it appears to me that we may arrive at a rational conclusion, which may 
be regarded at least as probable. If, as I have supposed, yellow fever 
arises from the combined influence of the marsh and animal miasmata, 
we have an easy way of accounting for the symptoms which arise, as 
well as an explanation of its nature. For, as we have seen in a former 
section, if the idio-miasmata be operating upon the system, it probably, 
on entering the blood, unites chemically with it, changing or decom- 
posing it in a greater or less degree, and this will explain the reason of 
the great prostration, the typhus and hemorrhagic tendency, and also its 
contagious characteristics. 

* That of Geneva, Central New York. 






YELLOW FEVER. 14,') 

If the paludal poison be operating upon the system in producing 
yellow fever, it probably, as we have already seen, on entering the 
blood, passes with it through the system as a foreign substance, producing 
its effects directly upon the brain and nervous system ; and this will 
account for the apparent remitting tendency, for its often running into 
or partaking strongly of the nature of bilious remittent and even inter- 
mittent fevers, and it will also account for the apparent similarity, in 
many respects, between the post-mortem appearances in bilious remittent 
and yellow fevers. 

If now, as I have supposed, both the koino and idio-miasmata are 
operating upon the system at the same time — the one decomposing or 
changing the blood, and producing the prostration, the hemorrhagic 
tendency, the black vomit, and the typhus characteristics, and the other 
producing the yellow skin, the remittent and other bilious characteristics 
— we have every symptom accounted for, and a rational solution of the 
nature or true pathology of yellow fever. 

That such is the true nature of yellow fever, I have not in my own 
mind a reasonable doubt. 

"With these considerations, I shall leave this part of our subject, hoping 
that the suggestions I have made may receive that degree of considera- 
tion on this truly perplexing question that they may deserve — not for my 
;<ake, but that the subject may be brought as near to a rational solution 
as it can well be from the circumstances by which it is surrounded. 

Prognosis. — Yellow fever is truly a fatal disease, partaking as it does, 
in my opinion, of the nature of typhus and bilious remittent fevers. We 
have, in addition to the dangers usually attending both these febrile 
affections, a degree of malignancy resulting from this combination, as 
well as from the peculiar virulence of the febrific agents which produce 
it. With these considerations, it is not strange that so many should be 
smitten down by this disease, especially when we remember that every 
species of imprudence and intemperance practised by the masses of the 
human family not only act to predispose the system to this disease, but 
also tend to develop the disease, where it is prevailing, in a way not con- 
ducive to a favorable result. 

Dr. Fenner estimates that about one-eighth of the cases occurring in 
New Orleans, in the epidemic of 1847, proved fatal.* Professor Dick- 
son estimates that the proportion of fatal cases in Charleston is about 
one-fifth or one-sixth, while the average loss in his own practice, in eight 
epidemics, during a period of about thirty years, was only one in fifteen. f 

The unfavorable symptoms are violent pains in the forehead, back, 
and limbs ; a frequent and feeble pulse ; a blood-shot appearance of the 
eyes ; a deep yellow skin or mahogany color ; short febrile reaction ; 
coma ; slow and difficult respiration, with hiccough ; restlessness ; a 
morbid appetite; black vomit; and, finally, a universal hemorrhagic 
tendency and great prostration. 

The favorable symptoms are a lengthened febrile reaction ; the occur- 
rence of gentle perspiration ; dark bilious evacuations ; cleaning of the 
tongue ; slight vomiting, subsiding early ; and a tolerable retaining of 

* N. Med. and Surg. Journal, v. 20G. f Charleston Med. Journal, xii. 744. 

10 



146 GENERAL FEVERS. 

the integrity of the system, and the absence of all the unfavorable symp- 
toms enumerated above. 

Treatment. — If we take into account the deviation from the standard 
of health in yellow fever, we shall have the indications for a rational 
treatment. 

It is fair to state, that in yellow fever we have a debilitated condition 
of the system, produced by a febrific agent or agents, which decompose 
or change the blood, and also produce a direct effect upon the brain and 
nervous system of a most debilitating character. And I believe it is also 
true, that nearly or quite every unfavorable symptom which arises during 
the continuance of the disease, is either directly or indirectly the result 
of debility, not excepting even the febrile reaction, which is evidently 
the result of irritation set up in the cerebro-spinal system during the 
chilly or cold stage, in congestive cases the system not retaining power 
enough to get up even an irritated reaction. 

This, then, being the deviation from the standard of health, the indi- 
cations are, plainly, to equalize the circulation ; to sustain the sinking 
powers of the system, and thereby keep up or restore the deranged 
functions of the body : to counteract local congestions and inflammations ; 
and, finally, to afford the patient sufficient nourishment, fresh air, and 
every comfort that may in any way be conducive to a restoration to 
health. 

In ordinary cases of yellow fever, then, at the period of attack, if 
febrile reaction has not been set up, it should be encouraged by rubbing 
the whole length of the back with a warm infusion of capsicum in vinegar, 
and the administration of warm drinks. And if there is severe pain in 
the head and back, the feet should be placed in warm water, rendered 
stimulating by mustard or capsicum. To aid in this, and prevent early 
congestion and inflammation, a mustard poultice may also be indicated 
over the whole abdomen, and, when it is, should never be neglected. 

As soon as these indications are fulfilled, if the patient be seen before 
reaction is set up, or at the very first, if the patient be not seen till 
reaction is established, a cathartic of calomel, to clear the alimentary 
canal of any irritating matters it may contain, should be administered. 
Ten grains may be given at once, and then half an ounce of the sulphate 
of magnesia given every six hours till the bowels are moved. 

Immediately on the operation of the cathartic, a sustaining course of 
treatment should be resorted to, as it is plainly indicated, and continued 
as long as treatment may be required — modified, of course, to meet the 
indications which are furnished in each particular case. 

In ordinary cases, to sustain the system, keep up its various functions, 
&c, four grains of quinine, with an equal quantity of Dover's and 
James's powders, may be combined, and given every four or six hours, 
with two or three grains of calomel, if the bowels are rather constipated 
and the case appears foreboding by a torpid inactive state of the liver. 
This prescription is well adapted for the febrile stage, the quinine pre- 
venting local congestions, and sustaining the system against an approach- 
ing collapse, and, as I believe, modifying, or in part neutralizing the 
febrific agent. The James's powder lessens the cephalic tendency and 
promotes perspiration, while the Dover's quiets nervous excitability, 



YELLOW FEVER. 147 

favors sleep, and also promotes perspiration, and finally, the calomel, 
when it is indicated, tends to equalize the circulation, promotes a healthy 
action of the liver and whole glandular system, and lessens the danger 
of local inflammations. 

This treatment may be continued during the febrile stage, with what- 
ever else may be indicated, such as sponging the surface with cool water, 
a blister to the back of the neck, and sinapisms to the epigastrium, and, 
if necessary, a blister. Immediately on the approach of collapse the 
Dover's and antimonial may be discontinued, and the quinine continued 
in five or six grain doses, with an equal quantity of camphor, with or 
without the calomel, every six hours, and continued with warm crust- 
coffee, one-half milk, and, if necessary, mutton or chicken broth, wine 
whey, &c, till either death or convalescence render them no longer 
necessary. 

To help restore the integrity of the blood, and to exert a styptic effect 
upon the mucous coat of the stomach, the tincture of muriate of iron 
has been used, and first, I believe, by the late Dr. Wildman, of Savan- 
nah. During the collapse from twenty to thirty drops of the muriated 
tincture may given in a little water, every six hours, alternating with 
the quinine. This course of treatment should be continued during the 
collapse, the quinine and camphor sustaining the sinking powers of the 
system, while the muriated tincture of iron not only acts as a styptic, 
but also probably tends to produce a favorable change of the blood, and 
is generally agreeable to the stomach. 

It may be noticed that I have said nothing of the period of abate- 
ment in the treatment, regarding the condition immediately on the sub- 
sidence of the febrile action as being either convalescence or tending to 
a collapse, and therefore requiring the increase of quinine with camphor 
in all cases, except, perhaps, in mild cases, in which it may be the com- 
mencement of convalescence, when often the doses of quinine, instead 
of being increased, may admit of being gradually diminished. 

If the vomiting be severe and obstinate, or if there is evidence of gas- 
tric inflammation, a blister should be applied to the epigastrium, after 
sinapisms have done their utmost, and, in some cases, a blister to the 
abdomen, below the umbilicus, may become necessary. To stop the 
vomiting when it is commencing, one grain of calomel, with a grain of 
Dover's powder, may be administered every fifteen minutes, till four or 
five doses are given, and often with very satisfactory results, as I have 
found in many cases. 

Such appears to be the general character of the indications arising in 
ordinary cases of yellow fever, and also the best mode of fulfilling them. 
But cases of a congestive character sometimes occur in which there is no 
febrile reaction, the vital powers being so far smitten down that the 
system will not arouse to even an irritated febrile state. In these con- 
gestive cases the same early treatment should be resorted to; such as 
stimulating frictions to the spine, the warm stimulating foot bath, the 
warm nourishing drinks, cathartic, &c. But, instead of commencing 
with the quinine in four or five grain doses, with the Dover's and anti- 
monial powders, ten grains of quinine and five grains of camphor may 
be given from the first every six hours, and alternating with it, from 



148 GENERAL FEVERS. 

forty to sixty drops of the muriated tincture of iron. And this treat- 
ment should be continued with baths, wine whey, and brandy if need 
be, and sinapisms, blisters, &c, as the case may require. 

In such congestive cases, if the quinine and camphor fail to arouse 
the system, ten grains of capsicum may be given with each dose of the 
quinine, or what would generally be better, alternating with it at the 
time of administering the iron. It is most conveniently given in the 
form of a pill, and may require in some cases to have combined with it 
a grain or two of opium to render it acceptable to the alimentary mu- 
cous membrane. 

During the whole course of the disease the patient should get as much 
nourishment in the form of crust-coffee and milk, broths, wine whey, 
&c, as the system requires and the stomach will retain. Great care 
should also be exercised to keep the apartments clean and well aired, 
and no case should be abandoned as hopeless while one vital spark 
remains. Thus I have completed what I had to say upon yellow fever, 
and also the general febrile affections, except plague and diphtheria, which 
I shall proceed to consider in the following sections. 

SECTION VII.— PLAGUE. 

By plague I mean a well-known general febrile affection endemic in 
Egypt, and other countries bordering on the Levant, and characterized 
by petechia, carbuncles, and swellings of the lymphatic glands of the 
groin, axillse, &c. I can only give a general description of plague, em- 
bracing the most prominent facts connected with it, as I have never seen 
a case. The description then which I shall give of this disease will not 
be from personal observation, but will be such as I have gathered from 
those who are familiar with the disease. 

It appears that plague is endemic in countries bordering on the Medi- 
terranean, and that it has made frequent eruptions into various parts of 
Europe, having visited at different times France, England and Germany, 
and having been exceedingly fatal in Paris and London in early times, 
according to the accounts furnished. 

It has been supposed, however, that Egypt is the only country where 
it is ever engendered, and that when it occurs elsewhere it is as an alien. 

In Egypt it is said to appear every autumn, and to prevail more or 
less till the following June, when its ravages cease and its contagion 
remains inactive till early autumn when the disease again prevails, being 
the most fatal about the time of the vernal equinox. It has been sup- 
posed to arise in Egypt from putrid emanations exhaling from the 
decomposition of animal and vegetable substances decomposed in the 
lakes, formed by the retiring of the waters of the Nile, or in the ceme- 
teries which its inundation often reaches. 

Symptoms. — The symptoms which arise in plague, as described, are 
similar in some respects to those of malignant typhus, the patient being 
very much prostrated early, with a sense of weight in the head, giddi- 
ness, and great depression of spirits. They are silent, making often 
little complaint, and having little fever they may appear to a careless 
observer as being only slightly indisposed, and yet they may be smitten 



PLAGUE. 149 

down, in some instances, within two or three days. In such rapid cases, 
however, no buboes or carbuncles make their appearance.* 

In other cases, though the first attack may be similar to that I have 
already described, the disease develops other and more prominent symp- 
toms in a few hours ; the eyes become dull, the extremities, and surface 
of the body become cold, there is drowsiness, and more or less pain in 
the region of the heart. As the disease advances, the patient loses the 
power of speech, is covered with a cold clammy sweat, the pulse becomes 
weak, and quick, there may be more or less delirium, but a comatose dis- 
position generally prevails. Towards the close there is great restless- 
ness. Buboes may appear in those w T ho continue to the fourth day, as 
well as petechia ; or else broad livid spots may occur, though the latter 
generally not till after death. 

Such are the ordinary symptoms of plague, as it appears in its most 
violent forms at the commencement of an epidemic. But at a later period 
in an epidemic, plague assumes a milder form, though still a very dan- 
gerous disease. In this milder, which is by far the most frequent form 
of plague, the disease commences with more or less coldness, which may 
amount to shivering, followed by fever, vomiting, and more or less giddi- 
ness and pain in the head. The fever increases during the day, and fol- 
lowing night ; but in the morning, there is usually a very perceptible 
remission. 

Usually in this form of the disease, carbuncles and buboes make their 
appearance on the first day, and successive eruptions of them may appear 
throughout the whole course of the disease. During the second day, 
there is an exacerbation of fever, the patient being afflicted witft nausea, 
distressing headache, severe pain in the swellings, and more or less con- 
fusion of mind, with a tendency to coma. The skin becomes hot, the 
pulse more frequent, and the tongue quite dry ; the patient being anxious, 
restless, and complaining of more or less pain in the region of the heart. 

During the following night, all the symptoms become aggravated ; the 
patient either raving incoherently, or else inclined to a profound stupor. 
Usually on the morning of the third day, there appears a gentle perspi- 
ration, with more or less abatement of all the more violent symptoms, 
and may even be the commencement of convalescence ; but it generally 
only furnishes ground for hoping that a favorable crisis may occur on 
the fifth day. It is said, that in all cases in which there is no sweating 
or remission on the third day, great danger is to be apprehended. 

The exacerbations may increase in violence up to the fifth day, at 
which time, the remission and sweating may be more considerable, leaving 
the patient faint and languid, but in every respect, improved or relieved. 
After the fifth day, the remissions may become gradually more marked, 
the exacerbations being lighter each day, and the buboes advancing to 
suppuration ; so that by the eighth or tenth day, little fever remains, 
except that which is symptomatic of the local inflammations. 

In some cases, all these symptoms are greatly aggravated, there being 

violent headache, vomiting, and purging, the face flushed, and eyes 

glistening, there is violent delirium or coma, the pulse is full and strong, 

the tongue dry, and thirst excessive, and the most distressing vomiting 

* See Russell's History of the Plague at Aleppo in 1760, 1761, and 1762. Page 96. 



150 GENERAL FEVERS. 

occurs, especially during the night. These symptoms may continue with 
only slight remissions, the exacerbations gradually becoming more vio- 
lent or distressing, till the tongue falters, the surface of the body be- 
comes cold, and covered with a clammy sweat, the vomiting and diarrhoea 
continuing, and often hemorrhages occurring from different parts of the 
body, the buboes appearing on the second or third day, do not suppurate, 
and in this way the patient, distracted and worn down, dies on the third 
or fourth day. 

In some cases, again, the carbuncles and buboes appear to be the pro- 
minent feature of the disease ; the patient has little lever, walks about, 
or even follows his accustomed avocations, as appears to have been the 
case with many soldiers in the French army in Egypt, during the Syrian 
Expedition ;* and it is stated on good authority, that in some instances, 
patients suffering from plague, have walked to within a few hours of 
death. 

The bubo of plague appears to be a swelling of the glands of the neck, 
axillae, and groin, and sometimes of the parotid, being at first deep-seated, 
and painful, but gradually advancing towards the surface, and generally 
proceeding to suppuration. They may terminate, however, in resolution, 
suppuration, or gangrene ; suppuration not being essential even to a fa- 
vorable termination, but rather a sign of a favorable termination. 

Besides the buboes which occur in glandular parts, tumors, which have 
received the same name, are often found on the head, neck, shoulders, 
chest, abdomen, or, in fact, on almost any part of the body, even the ex- 
tremities. These tumors may disappear, or pass on to suppuration, 
though it is said more slowly than the glandular bubo. Carbuncles may 
appear in various forms ; commencing generally, it is said, as a pustule, 
but sometimes like a vesication, filled with a yellow or blackish fluid. As 
they advance, they become hard, painful, and gangrenous, and form 
eschars, which spread, and destroy the skin, muscles, and sometimes even 
the tendinous parts. In fatal eases, the eschar, it is said, remains dry, 
with little or no appearance of being cast off; but in cases in which con- 
valescence is approaching, suppuration takes place around the eschar, 
by which it is soon cast off, leaving an ulcer of greater or less depth, 
which gradually heals during convalescence. 

Various other cutaneous affections have been described as occurring 
in plague ; such as petechiae, at first purple, and later of a livid appear- 
ance ; and an erysipelatous efflorescence of a transient character ; narrow 
streaks of a livid color upon the face, of a frightful appearance ; large 
blue or purple spots occurring in the most dependent parts of the body ; 
the result, probably, of infiltration, caused by the attenuated state of the 
blood. Thus we have an outline of the symptoms which are developed 
in plague, in the various forms which it assumes, in regions where it is 
endemic, or epidemic. Let us now proceed to inquire into its diagnostic 
symptoms, morbid anatomy, cause, nature, prognosis, and treatment. 

Diagnosis. ■ — It appears that there need be little, if any difficulty, in 
discriminating a case of plague, if the symptoms can be observed during 
its whole course, as most of the symptoms which are developed, are pecu- 
liar to this disease. But at the commencement of an epidemic, when 
* See Dictionnaire des Sciences Medicales, vol. xit.. p. 77. 



PLAGUE. 151 

the disease is usually very fatal, the patient may die early, or before its 
most peculiar symptoms are developed ; and thus the diagnosis may be 
attended with some difficulty. In such cases, the following diagnostic 
symptoms should be carefully noted : the inflamed appearance of the 
eyes ; the swelling of the tongue, and difficulty of articulation ; the tot- 
tering gait, &c. ; all of which, together with the extrinsic circumstances, 
such as the season of the year, the location, the possibility of exposure, 
&c, may aid in forming a correct diagnosis in most cases at least. 

But if, in addition to the symptoms which I have enumerated above, 
buboes, carbuncles, petechias, &c, make their appearance, the diagnosis 
may be regarded as certain, and every precaution which prudence can 
suggest should be taken to prevent a spread of the disease. And even 
where there is doubt, prudence would dictate that the patient be kept 
secluded for a sufficient time to allow the disease to develop its real 
character, for of all diseases plague is one most to be dreaded, on almost 
every account. 

Anatomical Characters. — Various morbid appearances have been de- 
scribed as being found, on post mortem examination of patients dead of 
plague, the most prominent of which are a changed condition of the 
blood, dark coagula being found in the heart, large arteries and veins, 
distension of the gall-bladder, with black or greenish bile ; black spots, 
probably of extravasation, through the lungs, heart, liver, stomach and 
bowels ; hemorrhagic effusion into the cellular tissue, and sometimes into 
the cavities ; an engorged and enlarged condition of the lymphatic 
glands ; and various accidental marks of inflammation, in different parts 
of the body, and especially in the alimentary mucous membrane. 

It is proper to state, however, that in some epidemics, at least, on 
post-mortem examination, everything is described as being found in a 
natural state, in some cases ; while in others, slight marks of inflamma- 
tion were found only in the intestines, and that was supposed to have 
been produced during the last moments of life.* It may be seen, then, 
that the principal morbid appearances, when any are found, are of the 
blood, and such as are produced by a poisoned, changed, or partially 
dissolved state of the blood. 

Cause. — Great differences of opinion have prevailed in relation to the 
origin of plague, and also in relation to the manner in which the disease 
is contracted ; whether exclusively from a peculiar state of the atmosphere, 
or by contagion, or both. From all the facts that I have been able to 
gather on this subject, I incline to the opinion that the disease, or the 
morbid poison which produces it, is engendered in Egypt, and perhaps 
in the lakes left by the subsiding of the waters of the Nile ; or, as has 
been suggested, in cemeteries which are often inundated, and then left 
exposed to the intense heat of the summer sun. 

Or, what is more probable, both these causes may conspire to gene- 
rate a morbid poison, from the accumulated animal and vegetable matter, 
which, on being brought to act upon a population filthy and intemperate, 
in many respects, as the lower classes of the Egyptians are, will readily 
produce the morbid condition of the system which has been called 
plague. 

* See Relations Historique de la Peste de Marseille, pp. 447, 448. 



152 GENERAL FEVERS. 

When the disease is once engendered, the bodies of patients suffering 
from it probably generate a specific contagion, which will communicate 
the disease from one individual to another, in all the modes in which 
diseases are thus communicated, by contact, by inoculation, through the 
atmosphere, and by fomites. This, then, accounts for the origin of the 
disease, which, being once generated, is liable to spread beyond the bor 
ders of Egypt, where it is endemic, and thus become a pest and terror 
in different parts of the world, where filth, intemperance, and various 
other causes predispose to it. 

It may be communicated, probably, to regions not too remote, directly 
from the lakes or cemeteries where it is generated, by the prevailing 
wind, and to regions more remote by ships, infected goods, and from the 
bodies of persons suffering from the disease. It has been a question 
whether the bodies of the dead retain an infecting power. But I think 
the weight of testimony is decidedly in the affirmative. This was par- 
ticularly noticed in the epidemic of Marseilles, in the year 1720, and 
also in the plague of London, of 1665. 

The latent period of this disease has been an important question, on 
account of quarantine regulations. It appears that the disease may de- 
velop itself, after exposure, at any time from a few hours to the tenth 
day, and perhaps at a later period. But the length of time that con- 
tagion may adhere to infected goods, not ventilated, is probably much 
longer than that. It has been noticed that extremes of temperature 
modify, or check, the activity of the cause which produces plague. 
Hence it is, that the abatement of the pestilence takes place along the 
Mediterranean during the heats of summer, while in the North of 
Europe, it has been during the cold of winter. 

In relation to the causes which predispose to plague, there can be no 
reasonable doubt, but that filth, intemperance, licentiousness, and in fact 
every deviation from the laws of health, not only predispose the system 
to this disease, but also render the air impure, in consequence of which 
it becomes a more ready medium for communicating the contagion. 

Nature. — In relation to the nature of plague, there may be room for 
doubt ; and yet I think it is rational to infer that a poison, probably the 
result of the decomposition of animal and vegetable matters, is taken 
into the blood, through the skin and lungs, and effects a marked change 
in all the fluids and the solid tissues of the body. That this morbid 
poison is more animal than vegetable, and that it is taken into the sys- 
tem, in part at least, by the absorbents of the skin, appears to me 
reasonable. 

And if so, it accounts in part for the buboes which occur, the lym- 
phatic glands being irritated by the poison which is carried through 
them by the lymphatics, very much as we see from animal matter taken 
up by the absorbents, in dissection wounds. But in those rapidly fatal 
cases of plague, in which no buboes appear, it is probable that a very 
concentrated poison enters the blood, through the skin and lungs, in 
sufficient quantity to change at once the blood and solid tissues, and thus 
by a shock to the brain and nervous system, to destroy life, before the 
lymphatic glands have time to become inflamed, as we see in somes cases 
of poisoned or dissection wounds. 



PLAGUE. 153 

Prognosis. — Plague has been regarded, and is really one of the most 
fatal diseases which afflicts the human family; the general prognosis in 
relation to its spreading, if introduced into a place, is in the highest de- 
gree unfavorable, unless the first cases admit of being totally secluded, 
that a general contamination of the inhabitants may not be produced. 
And the mortality of cases actually attacked with plague is surpassed, I 
believe, by few, if any maladies which have ever prevailed since the 
creation of man. It is estimated that in the plague, as it generally pre- 
vails, at least fifty per cent, of those attacked perish. In the plague at 
Marseilles, in 1720 and 17^1, it is supposed that of a population of 
80,000, about 40,000 fell victims to the disease, though about 10,000 
escaped infection.* 

In individual cases, hiccough, cardialgia, diarrhoea, convulsions, and 
colliquative sweats, are unfavorable symptoms, while the favorable signs 
are the occurrence of buboes, passing on to regular suppuration, a mild 
but well-developed febrile reaction, a gentle perspiration occurring at 
the remissions, and finally, the absence of all the more violent symptoms 
common to this most malignant disease. 

Treatment. — As there is some doubt in relation to the real pathology 
of plague, there must of necessity be a little uncertainty in relation to 
the real deviation from the standard of health, as well as to the indica- 
tions and best mode of fulfilling them. If, however, the morbid condi- 
tion consists, as I have supposed, of a poisoned state of tne whole system, 
both of the fluids and solids, and that, too, by a poison originating in 
the decomposition of animal and vegetable matters, but chiefly of animal, 
or else being generated in the systems of patients suffering from plague ; 
we have a tolerable idea of the deviation from the standard of health, 
which may suggest for us the indications, and a rational mode of fulfill- 
ing them. 

To sustain the sinking powers of the system, prevent local congestions, 
and consequent passive inflammations, to promote perspiration, favor a 
healthy action of alf the functions, and hasten suppuration of the buboes 
when they occur, are evidently the indications to be fulfilled. 

To arouse the system, equalize the circulation, and promote perspira- 
tion, it appears to me, an emetic of ipecac , at the very first, might be 
serviceable, and unless in some way contra-indicated, would be worth a 
trial. To clear the alimentary canal, and also to help equalize the cir- 
culation, if no diarrhoea be present, a mild cathartic would appear to be 
indicated. And that which would suggest itself to me, would be twenty 
grains of rhubarb, and ten grains of hydg. cum creta, and followed, if 
necessary, by a seidletz powder. Immediately on the operation of the 
cathartic, I would apply sinapisms to the feet ; cups, and if necessary, 
blisters to the back of the neck, and give at once three or four grains of 
the sulphate of quinine, with an equal quantity of Dover's powder, 
every six hours, and this, I think, might be continued till the fever sub- 
sides. 

On the subsidence of the fever, I would discontinue the Dover's, and 
continue the quinine, with an equal quantity of camphor ; in a few days 
discontinuing the camphor, and gradually lessening the dose of the 

* See Traite de la Peste, p. 464. 



154 GENERAL FEVERS. 

quinine. The quinine and Dover's early, would sustain the system 
and promote perspiration, while the quinine with camphor, in the latter 
stages, would sustain the system, and also quiet nervous excitability. 
And though the febrile excitement be very great, and local inflammations 
appear to be forming, I should have no fears from the quinine, for I 
believe they are generally of a passive character, which would be 
relieved instead of aggravated by the quinine, as I have witnessed in 
severe cases of dissection wounds, or poisoning from animal matter. 

I would allow the patient early, crust coffee, or toast-water, one half 
milk ; and later, the same, with chicken broth, wine whey, &c, if they 
were in no way contra-indicated. And as soon as solid food could be 
borne, a poached egg, toast, mutton, &c, taking care to allow the sys- 
tem as much nourishment as it will bear, during the whole course of the 
disease. To favor suppuration of the buboes, and separation of the 
eschars in the carbuncles, a poultice of flax-seed, slippery elm, or bread 
and milk, appear plainly indicated ; and to the ulcers which follow, 
gently stimulating or soothing applications may be indicated, according 
to the condition of the patient. 

Such, it appears to me, are the indications in the treatment of plague, 
and also the best mode of fulfilling them in its ordinary form. But in 
those rapid cases in which there is an early sinking, without the appear- 
ance of buboes or carbuncles, I would omit the emetic and cathartic, and 
give at first quinine and camphor in full doses, and if necessary, wine 
whey, broths, brandy, &c. During the whole course of the plague, 
cleanliness, fresh air, and every possible care to prevent the spread of 
the disease should be carefully attended to. 

SECTION VIII.— DIPHTHERIA. 

By diphtheria, from the Greek 8i$9spa, <a membrane,' I mean here that 
peculiar malignant febrile affection, which, being so # generally aTfended 
with the formation of fibrino-albuminous membranes, especially in the 
fauces, larynx, trochea, &c, has been called sore throat, 'putrid sore 
throat, malignant sore throat, Sfc. The term is objectionable; but as it 
indicates one of the most prominent features of the disease, it may be 
the best term we can get for this truly malignant febrile affection. 

I introduce diphtheria in this place because I think it is emphatically a 
febrile affection, and should thus be classed, and not regarded or treated 
as a throat, but as a general blood disease, partaking of the nature of 
typhus and other malignant fevers ; the throat complications being the 
effect of the general condition, and not the primary disease to be eradi- 
cated. And though the disease is in some cases attended with a scarlet 
rash, I do not believe that it is properly an exanthematous fever ; espe- 
cially as enteric and typhus fevers are not generally classed as such, 
though they are attended in most cases with a slight exanthema. I 
have, therefore, placed diphtheria with the general fevers, and the last of 
the list, following typhus and plague, believing that in so doing, I have 
it where pathologically it belongs. 

Diphtheria may have prevailed more or less extensively in various 
localities at different periods, but it has been especially prevalent in 



DIPHTHERIA. 155 

Europe and America during the past few years, in some localities assu- 
ming a mild, while in others it has assumed a decidedly malignant char- 
acter. In this respect diphtheria does not differ materially from other 
malignant fevers, as some cases even of the plague are said to be so 
mild that soldiers have not left the ranks for even a day while laboring 
under the disease. 

Symptoms. — In mild cases of diphtheria there is generally a slight 
feeling of weariness or languor for two or three days, or perhaps longer, 
with partial loss of appetite, especially in the morning, a slight headache, 
a heavy feeling in the lumbar region of the back, and sooner or later 
slight chilliness, followed by moderate febrile action. Soon after the 
febrile reaction the patient feels a slight soreness of the fauces, and 
there is a swelling of one or both tonsils, and very soon the parts in- 
flamed, generally including one or both tonsils, are covered with a 
fibrino-albuminous membrane, continuous or in patches, and of a gray, 
brown, or blackish color. 

In some cases, especially in children, the symptoms of the forming 
stage, and even the chill and fever, are scarcely noticed, the soreness of 
the throat being the first symptom complained of, attended with a slight 
swelling and soreness of the glands of the neck at the angle of the jaws. 
In these mild cases the fibrino-albuminous membrane is apt to be of a 
lightish color, and is often thrown out in patches, instead of a continuous 
membrane. 

In severe malignant cases of diphtheria we have, however, a much more 
violent train of symptoms. The forming stage is attended with a feeling 
of great prostration, the appetite fails, the tongue becomes coated of a 
darkish color, the breath becomes offensive, the patient becomes nervous, 
restless and irritable, and within two or three days from the appearance 
of these premonitory symptoms, there comes a chill, more or less severe, 
attended with headache, pain in the back, &c, and followed in some 
cases by moderate, and in others by considerable febrile reaction. 

The fever for two or three days is usually slightly aggravated about 
the hour the first febrile action was set up after the first chill, but though 
the pulse may be frequent, and in some cases tolerably full, yet it is not 
strong, indicating from the very first great nervous prostration, and, in 
some cases, as in other congestive malignant fevers, little or no reaction 
takes place, the powers of life steadily sinking from the first* Soon 
after the first chill, however, whether reaction occur or not, the fauces, 
and especially the tonsils, become more or less swelled, and in congestive 
cases the glands of the neck about the angles of the jaws become very 
much swelled, and often present a frightful appearance. 

The fibrino-albuminous exudation, in severe cases, may form a con- 
tinuous membrane, of a dark gray or brownish color, covering the palate, 
uvula, tonsils, fauces, and inner surface of the larynx, trachea, and 
bronchial tubes. In some severe cases, especially of a congestive char- 
acter, suppuration occurs in one or both tonsils, in which case there may 
be but slight exudation upon any of the mucous membranes, the matter 
in such cases having the same dark grayish appearance which the exu- 
dation presents, and the same offensive, putrid smell. 

In severe cases, unless early arrested, the face and neck become 
bloated and pale or livid,, a bluish streak appears around the mouth, there 



156 GENERAL FEVERS. 

is a constant cough, with expectoration of detached portions of the exu- 
dation, along with a more fluid fibrino-albuminous matter unorganized, 
a sanious matter runs from the nose, the pulse becomes frequent, quick, 
and fluttering, the extremities become cold, and the patient dies about 
the fifth or sixth day of the disease, either from general prostration of 
vital power, or from retention of carbon in the blood, caused by inter- 
ruption of the respiration, or shutting off of oxygen by obstruction either 
in the fauces, larynx, or bronchial tubes. The patient may, however, 
die within forty-eight hours after the attack from congestion, or from 
the direct effects of the poison which produces the disease, anting upon 
the blood and cerebro-nervous system, directly destroying vitality. 

Causes.— Now in this, as well as in all putrid fevers, every imprudence 
and deviation from the laws of health, such as exposure, want, improper 
food and clothing, low damp apartments, filthiness of every kind, &c, 
act as predisposing causes of this febrile affection. In addition to all 
this, it is probable that a damp atmosphere, such as always exists in 
some localities, from protracted rains, or from warm weather at seasons 
when it is always wet but usually cold, has very much to do in predis- 
posing to or even producing this disease. 

A damp atmosphere at such seasons of the year operates to depress 
vitality, and thus predispose to this disease in part by checking perspi- 
ration, and thus causing to be retained in the blood the perspirable 
matter. It is probable, however, that it is the low electrical state of 
such damp air, letting down as it does the electrical condition of the 
system, and thus deranging all its functions by a failure on the part of 
the brain and nervous system to generate and distribute sufficient nervous 
influence or vital force, that damp air becomes more especially a cause 
of this disease. On the temperate, well fed, well clothed, and cleanly, 
whose blood is kept up to the standard of health, this low electrical state 
of the air may scarcely operate unfavorably, but not so with the unfor- 
tunate children of want, who are half fed, half clothed, and filthy withal, 
or with the intemperate, imprudent, licentious, &c, whose blood is always 
below the standard of health. 

I am satisfied, however, that in every case of diphtheria there is an 
animal poison introduced into the blood, either from the bodies of those 
suffering with the disease, or else arising from an accumulation, and per- 
haps decomposition of various animal secretions and exhalations, consti- 
tuting idio -miasmata. I believe, also, that the paludal poison, in mala- 
rious districts, is often combined with the animal poison, rendering the 
disease more malignant, and giving it, in some cases, a slight remittent 
character. 

While then exposure, want, dampness, and a low electrical state of 
the air, as well as every possible deviation from the laws of health, pre- 
dispose to diphtheria, I am confident that either a contagion generated 
in the bodies of patients suffering from the disease, or else an idio- 
miasmata resulting from animal filth, invariably enters the blood, either 
through the skin, stomach or lungs, and so far decomposes or changes 
the blood as to lead to the prostration, chill, &c, and this dissolved state 
of the blood accounts for the putrid smell, the exudation of the putrid 
fibrino-albuminous matter, and in fact for every essential feature of the 
disease. 



DIPHTHERIA. 157 

While then the above cause or causes, if a contagion be generated in 
the disease, are. as I believe, essential to the development of this febrile 
affection, koino-miasmata, when present in the blood at the same time, I 
am confident may very materially modify the disease, rendering it more 
malignant, and rendering the fever in many cases of a slightly remit- 
tent character, as it is liable to in other typhus or putrid fevers when it 
enters the blood with the animal poisons. 

I have suggested the possibility of a contagion being generated in the 
bodies of patients suffering from this disease, and while I am not quite 
certain that such is the case, I am confident that an exposure to putrid, 
or even mild cases, renders the person thus exposed much more liable to 
an attack, and this conclusion is not the result of a limited, but of a 
careful and extensive observation in a variety of cases too numerous to 
mention in this place. This fact, however, is not positive evidence of 
contagion in these cases, for it is probable that idio-miasmata, or a gene- 
ral animal poison, would more generally arise in a degree of concentra- 
tion sufficient to produce the disease in another in apartments where 
patients were kept with this or any putrid disease, even though no spe- 
cific contagion were generated. 

Diagnosis. — The diseases with which diphtheria is perhaps most liable 
to be confounded are typhus fever and scarlatina, from either of which, 
however, it may generally be distinguished by careful attention to all the 
symptoms. Diphtheria differs from typhus in the exudations of the 
fibrino-albuminous matter which occurs on the mucous membrane of the 
mouth, throat and respiratory tubes, and in there being generally less 
stupor, and also less mental disturbance. From scarlatina it may be 
distinguished by greater prostration during the forming stage, the un- 
certainty of and irregular appearance of the scarlet rash which some- 
times appears, the offensive putrid smell, and by the very decided 
tendency to the formation of the fibrino-albuminous membrane on the 
surface of the mucous membrane of the mouth, throat, and respiratory 
tubes. The rash too, when it appears, is liable to be of a darker color 
than is common in most cases of scarlatina. 

Anatomical Characters. — On examination after death from diphtheria, 
the morbid appearances that are characteristic of the disease are those 
that are presented by the mucous membrane of the pharynx, larynx, 
trachea, and bronchial tubes, and also the changed appearance of the 
inner surface of the heart arteries and veins, as well as the changed ap- 
pearance of the blood itself. 

The mucous membrane of the pharynx, and frequently of the mouth, 
are either covered or have patches of a fibrino-albuminous membrane of 
either a lightish gray or dark brown color, if it has not been cast off 
before death, and if it has, the mucous membrane presents a swelled or 
congested appearance, as is usual after passive inflammation in a mucous 
membrane. The tonsils show signs of having been inflamed, and are 
often found enlarged, and present a dark congested appearance. 

The mucous membrane of the larynx and trachea is more or less 
covered with the fibrino-albuminous membrane, either forming a continu- 
ous membrane or else in patches, if it has not been thrown off, as hap- 
pened in one case in this village, the membrane forming a perfect tube, 
the exact shape of the larynx and trachea down to its bifurcation. This 



158 GENERAL FEVERS. 

tubular membrane was coughed up by a girl, I believe about twelve years 
old, and was preserved by my friend Dr. Jedediah Smith, of this village. 

The bronchial tubes are usually found filled with fibrino-albuminous 
matter in a viscid unorganized state, and in a case which I witnessed a 
few days since, examined by Dr. C. N. Hewitt, the lungs presented an 
emphysematous appearance, evidently from the entrance of air into the 
smaller bronchial tubes and air cells without the possibility of escaping 
past the viscid putrid matter which they contained. The heart clot in 
this case had the color and general appearance of unorganized fibrino- 
albuminous matter, and appeared to have been continuous through one of 
the valves, as if it might have been partially organized, and possibly inter- 
rupted its action during the last stages of the disease. 

The inner surface of the arteries, veins, and even the lining mem- 
brane of the cavities of the heart, are liable to be found covered more 
or less with the fibrino-albuminous membrane, as was found in a case 
examined by Dr. Jedediah Smith, a few months since. Other parts and 
structures are liable to present morbid appearances, but none that I am 
aware of but what are common in other putrid fevers. The blood is 
found of a dark color, and presenting an appearance of having been 
decomposed or materially changed. Evidences of passive inflammation 
may also be detected in some cases in the lungs, pleura, alimentary mu- 
cous membrane, and other structures, as in cases in which death has 
occurred from other putrid fevers. 

Nature. — I need not say much in relation to the nature or pathology 
of this disease. It appears to me clear, that an animal poison in every 
case is introduced into the blood, which, on entering it, acts in conjunc- 
tion with the predisposing influences which I have named, to decompose 
or materially change the blood ; and this changed condition of the blood, 
together with the direct action of the animal poison upon the cerebro- 
nervous system, interrupts the due generation and proper distribution of 
the nervous influence or vital force, and so there comes a chill more or 
less marked. In cases in which the paludal poison is also acting in con- 
junction with the animal, the disease is liable to be more malignant, and 
the fever to be of a slightly remittent character. 

Now, the fibrin and albumen of the blood being in a partially dissolved 
state, it is readily poured out, or allowed to transude from the capillaries 
of all the tissues, but especially so from the exposed surfaces of the 
pharynx, larynx, trachea, bronchial tubes, and inner surface of the 
heart, arteries, and veins, and hence the fibrino-albuminous exudation 
which occurs, sometimes as an organized, and, in other cases, as inor- 
ganized matter in these situations, in this disease. This fibrino-albumi- 
nous exudation may be favored by the passive inflammation which is 
liable to be set up in the parts from which the exudation occurs, but I 
think that congestion, with perhaps slight irritation of the structures, is 
all that is requisite for the exudation in its unorganized state, at least, 
provided the decomposed fibrin and albumen exist in the blood, or if the 
blood be in a decomposed or materially changed condition, as I believe 
it always is in this disease. 

It may be difficult to account for the special tendency in this disease 
to this fibrino-albuminous exudation, so especially upon the mucous 
membrane of the nose, pharynx, larynx, trachea, and bronchial tubes ; 



DIPHTHERIA. 159 

and yet. when we remember that the depraved materials exist in the 
blood in this disease, and that this fever generally prevails in damp 
weather, and at seasons of the year when catarrhal, throat, and bronchial 
affections occur, it is not strange that the exudation should take place 
just as it does. There is nothing more singular in this, than that buboes 
should occur in plague, or eruptions about the mouth in paludal fevers. 
I do not, however, believe that the fibrino-albuminous exudation is essen- 
tial to this disease, as I have had many cases developing early all the 
premonitory symptoms common to this disease, some of which have as- 
sumed the character of congestive typhus in the latter stages, while 
others have assumed a typhus character, being complicated with passive 
inflammation of the pleura, lungs, or some other organ or structure of 
the body. These cases, it may be said, were not diphtheria ; but they 
had every appearance of the disease early, and many of them had even 
the soreness of the fauces, especially those that assumed the typhus 
character, with pneumonia, pleuritis, &c, the difficulty of the throat dis- 
appearing as the pulmonary or pleuritic inflammation became developed. 
I have also noticed, that in cases of diphtheria in which even abscesses in 
the tonsils occur, there is liable to be very little organized fibrino-albu- 
minous membrane on the mucous surfaces, the matter, however, in the 
abscesses presenting a dark putrid appearance. It may be asked if the 
pathology of this disease be so near that of pure typhus fever, why there 
is not the coma and mental disturbance so common in that disease. I 
answer that it may, and sometimes does occur ; but I suspect that in 
cases in which there is marked irritation or passive inflammation of the 
fauces, larynx, or trachea, &c, this fact hinders, in part, the cephalic 
condition which develop those symptoms in pure typhus ; and, besides, 
fatal cases of diphtheria, in which these symptoms would be most liable 
to occur, generally terminate by the fifth or sixth day, and, therefore, 
before we should look for the development of these symptoms if they 
were to occur. 

Prognosis. — The prognosis in mild cases of diphtheria, if properly 
treated in season, may be regarded as generally favorable. In severe 
malignant cases, however, especially if neglected in the early stages, the 
prognosis may be regarded as generally unfavorable. The favorable 
indications are but slight premonitory disturbance ; a moderate or imper- 
ceptible chill; but moderate fibrino-albuminous exudation, and that of a 
lightish color ; and slight general fever or disturbance of the functions 
of the body. 

The unfavorable indications are great prostration during the forming 
stage ; loss of appetite ; a foul and even putrid breath ; a severe chill ; 
extensive passive inflammation of the fauces, larynx, trachea, or bron- 
chial tubes ; very extensive fibrino-albuminous exudation, either in an 
organized or very viscid form ; and the early development of very decided 
typhus symptoms. 

Treatment. — The indications in the treatment of this disease are evi- 
dently to equalize the circulation ; to sustain the sinking powers of the 
system ; to restore the blood ; and to prevent, as far as may be, suffoca- 
tion ; and, in most cases, especially in paludal localities, to attend to the 
hepatic or bilious complications. 



160 GENERAL FEVERS. 

In most cases, a cathartic of three blue pills, followed by half an 
ounce of castor oil, or of three grains of podophyllin, or five grains of 
leptandrin, or, if the patient be a child, of rhubarb, "with a little hydg. 
cum creta, is generally indicated, especially in paludal localities. The 
warm foot-bath should be used morning and evening, and the patient 
should be required to drink freely of either sage tea or crust coffee, one 
half milk, to be taken a little warm, for the purpose of promoting per- 
spiration, and, at the same time, to furnish proper materials for making 
good blood. 

A warm, dry flannel, folded so as to be of two or three thicknesses, 
should be pinned around the neck, sufficiently wide to extend up to the 
ears, for. the purpose of keeping the surface of the neck warm, and thus 
promoting perspiration, as well as relieving the congested, irritated, and 
perhaps inflamed, structure of the fauces ; including, generally, the ton- 
sils. Other more stimulating applications, as sinapisms, may be required, 
if the inflammation assumes in any degree an active appearance ; but I 
believe the dry flannel will generally do best, in the great majority of 
cases at least. 

To sustain the sinking powers of the system, and to arrest the fever, 
two or three grains of quinine, for an adult, or equivalent doses for chil- 
dren, should be g.iven every four or six hours, and continued during the 
whole course of the disease ; and after the general and local disease is 
arrested, the dose of quinine should be continued in gradually diminished 
doses, at least three times per day, during the whole period of convales- 
cence. In malignant cases, it may be best to give, during the progress 
of the disease, alternating with the doses of quinine, ten or fifteen drops 
of the tincture of muriate of iron, for the purpose of sustaining the blood 
as far as may be ; but I think the inconvenience of taking it to the 
patient, may in many cases more than counteract the benefit it is likely 
to produce, especially if there be great difficulty of swallowing, and 
especially, also, as the system in such a state appears to be incompetent 
to appropriate only the simplest forms of nourishment, and hardly to 
heed remedies, except such as act directly to sustain the sinking powers 
of the cerebrc-nervous system. Great discretion should, therefore, be ex- 
ercised in prescribing this remedy, as mild cases may not need it, and 
malignant cases might not heed, or be able to appropriate it. 

As a gargle, for the purpose of clearing and cleansing the throat, I 
prefer a solution of muriate of ammonia, in vinegar and water, for adults, 
or for children over eight years old ; but for children under that age, a 
solution of common salt in water, as it is less stimulating, and there- 
fore better borne. The solution of the muriate of ammonia may be 
varied in strength ; but two drachms, dissolved in half a pint of vinegar 
and water, consisting of one part of vinegar to two of water, is a medium 
strength. The solution of muriate of soda or common salt, for children, 
may be varied from two to four drachms, to half a pint of water, accord- 
ing to the age of the child. These gargles may be used every four or 
six hours in the early stages of the disease, but later, only three times 
per day, after each meal. 

Astringent gargles may be indicated in the latter stages of the disease, 
especially if the inflammation, on subsiding, has left a congested con- 



DIPHTHERIA. 101 

dition of the fauces, with move or less irritation of the mucous mem- 
brane. Or in some cases which early assume this appearance, astringent 
gargles may be used alternately with the cleansing gargles which I have 
suggested, perhaps from the very first. For adults, an astringent gargle 
made by dissolving half a drachm of tannin, in eight fluidounces of 
water, or of equal parts of vinegar and water, if it be desirable to render 
it more stimulating, will, I believe, generally do best. For children, I 
prefer a strong sage tea, sweetened with honey or loaf sugar, with the 
addition of half a drachm each of alum and borax, to a half pint of the 
tea. These astringent gargles may be used in the early stages of such 
cases as they may be indicated, every four or six hours, alternating with 
the cleansing gargles. In cases, however, in which they are only indi- 
cated in the latter stages of the disease, these astringent gargles may be 
used only morning and evening, the cleansing gargles being used after 
each meal at this stage, if required at all. 

The bowels should be kept regular, after the first cathartic, by small 
doses of castor oil, if necessary, and at such times as the patient does 
not take sufficient nourishment in his drinks of sage tea, or crust coffee, 
one-half milk, the proportion of milk should be increased ; and besides 
this, broths, beef essence, and wine whey, may be given in addition ; and 
finally, in cases in which the quinine, together with the nourishment I 
have suggested, fail to sustain the sinking vital powers, equal parts of 
whisky, or brandy and water, should be sweetened, and administered as 
freely as it may be required. 

I do not believe that the throat should be touched with anything that 
can possibly irritate, at any stage of the disease, unless it becomes abso- 
lutely necessary. If, however, the patient be likely to suffocate from an 
accumulation of viscid matter in the fauces, it may be carefully wiped 
out by a swab, wet in one of the astringent gargles I have suggested. 
Or if partially detached membranes are interrupting respiration, and 
they cannot be removed with the swab, as I have suggested, they may be 
carefully removed by a pair of bent forceps. Or, again, should the ton- 
sils so far fill the fauces, as to render suffocation from this cause in- 
evitable, they should be carefully cut off with Fahenstock's, or some other 
suitable instrument for the purpose. Finally, as a last resort, should a. 
closure of the larynx render suffocation certain, without a resort to tra- 
cheotomy, this last chance should be given to the patient, provided it be 
a favorable case of suitable age ; and provided, also, the patient and 
friends desire to avail themselves of so uncertain a chance, rather than 
submit to an inevitable fate.* 

Thus have I completed what I had to say on diphthe?'ia, as well as on 
all the general fevers. I will, however, suggest, that as soon as the 
patient acquires an appetite for food, it should be allowed in suitable 
forms, and at regular meal hours, through the whole period of con 
valescence. 

* Perhaps " tubing the larynx," through the mouth, might do in some cases instead. 
11 



CHAPTER V. 
EXANTHEMATOUS FEVERS. 



SECTION I.— VARIOLA— {Small-pox.) 

By -variola or small-pox I mean that variety of exanthematous conta- 
gious febrile affection which is characterized by fever, an eruption, first 
pimply, but passing on to a vesicle, and finally to a pustule ; the dura- 
tion of the disease varying from two to three weeks. 

Much has been said in relation to the origin of small-pox ; some being 
disposed to regard it as a disease of recent origin, or as having origi- 
nated about the A. D. 550. But it appears to have prevailed in India 
and China at a period long anterior to this, and it is possible that the 
disease with which Job was afflicted, near three thousand years ago, 
may have been small-pox. 

Small-pox occurs under a variety of modifications, from the most 
malignant to the merest varioloid affection, all, however, depending upon 
the same cause, and being propagated by a specific contagion. Two 
varieties, however, the distinct and the confluent, are entitled to con- 
sideration, though they are one and the same disease. In that which is 
usually called the distinct variety, the pustules, are distinct, elevated, 
distended and circular, and are scattered over the surface of the body, 
while in the confluent, the pustules are exceedingly numerous, depressed, 
irregularly circumscribed, and coherent or confluent. 

The time which elapses between the reception of the variolous virus 
and the first manifestation of its influence on the system, is generally 
from eight to fourteen days. During this period of incubation, no 
symptoms of indisposition generally manifest themselves, the individual 
retaining apparently a usual state of health. 

Distinct Variety. — Symptoms. — The disease commences with a feel- 
ing of languor, weariness, pains in the back and lower extremities, slight 
chills, with flushes of heat, and pain in the forehead. As the disease 
progresses, there is usually more or less nausea and vomiting, with thirst, 
pain in the epigastrium, and more or less soreness in the fauces. When 
the fever is developed, the skin is hot and dry, the tongue white, with a 
red point, the bowels torpid, and the urine scanty and high colored. 

During the first and second days of the fever the mind often becomes 
dejected and confused, and towards the end of the third day the tongue 
acquires a bright red color. And just before the appearance of the 
eruption there is an unusual tendency to perspiration, generally in adults, 
and usually drowsiness, and sometimes coma. In children, the eruption 
is often preceded by convulsions, there being much less tendency in them 
to free perspiration than in adults. The hands and feet, especially of 
children, may remain cold during the whole course of the disease. 



VARIOLA. 163 

There is sometimes an increase of the febrile symptoms a short time 
before the eruption begins to make its appearance, attended in some 
cases with severe cramps in the limbs, and violent pains in the back. 
Usually towards the end of the third, or beginning of the fourth day, 
the eruption begins to make its appearance. It comes out first upon the 
forehead, face and neck, and soon upon the breast and forearms, and 
lastly upon the abdomen and lower extremities, so that in about twenty- 
four hours, or at the close of the fourth, or beginning of the fifth day, 
the eruption is completed, and the fever has nearly or quite disappeared. 

The eruption consists at first of minute red points, which, by the 
middle of the second day of the eruption, the sixth day of the disease, 
become slightly elevated, with inflamed bases, but which as yet discharge 
no serum when punctured ; but the cuticle appears slightly distended by 
a semi-transparent lymph, so that the pimple has become a vesicle. 

By the third day of the eruption, the seventh day of the disease, the 
vesicles are fully formed, being round, with a central depression, which 
depression is generally perfected by the fourth day of the eruption, the 
eighth day of the disease, so as to become conspicuous in most of them. 
When, however, but few pustules exist, they may have only a slight 
central depression, but they generally assume the umbilicated form. 
The fluid appears first in the central point of the vesicle, and is of a 
serous character. But as the vesicles increase in size, they gradually 
assume a whitish color, and become pustular, being surrounded by a 
pale red areole. If the pustules are numerous, these areole may run 
into each other, and give a uniform redness to the interstitial spaces. 

The fluid which appears in the central part of the vesicle becomes 
gradually more abundant as it becomes purulent in character, consti- 
tuting the vesicle a pustule. This change is fully commenced, as we 
have seen, at the perfection of the vesicle, on the fourth day of the 
eruption, and the eighth day of the disease, and marks the commence- 
ment of the stage of suppuration. 

In the distinct variety, the fever which precedes the eruption always 
remits, and frequently disappears entirely, as soon as the eruption is 
completed ; but the febrile symptoms reappear when suppuration com- 
mences. And as the suppuration goes on the pustules lose their flat- 
tened form, are distended with pus, and become spherical. At the com- 
mencement of suppuration, about the eighth day of the disease, the face 
swells considerably, but it may subside in two or three days, and the 
hands and feet, and much of the surface of the body, in turn become 
swelled and tender in the same manner. 

The period of suppuration is usually attended with more or less 
soreness of the fauces, and increased secretion of the saliva, the mouth 
and throat being swelled, and of a bright red color. During the latter 
period of the suppurative stage, a peculiar odor arises from the patient's 
body, and this continues till desiccation is completed. There is also 
frequently more or less drowsiness, and occasionally a diarrhoea towards 
the completion of the suppurative process. 

The secondary, or suppurative fever, which begins about the eighth 
day of the disease, varies in violence and duration, according to the 
copiousness of the eruption, and the greater or less activity of the sup- 



164 EXANTHEMATOUS FEVERS. 

puration. In mild cases, the suppurative fever rarely continues more 
than four days, or to the twelfth day of the disease, as it commences 
about the eighth. The suppuration, like the eruption, begins on the 
face, and gradually extends to the extremities, being completed, and the 
pustules at their maturity at about the twelfth day of the disease. 

After the pustules have acquired their full state of development, at 
about the twelfth day, they sometimes remain stationary for several 
days, but they generally assume a brownish appearance at the centre of 
each pustule soon after suppuration is completed, and the liquid oozing, 
they acquire a rough, deep yellow appearance. Soon after they assume 
this appearance, the pustules shrink and become gradually drier, darker 
and harder, till the matter is converted into a brown crust or scab. 
Desiccation commences on the face, and extends gradually to the body 
and extremities, so that the scabs begin to fall from the face about the 
fourteenth day, and are all off the body, and even the extremities, by 
the twenty-first day of the disease. 

Thus we see that the eruption of pimples makes its appearance by the 
beginning of the fourth day of the disease. The pimples by the seventh 
day of the disease, contain a little lymph, constituting the pimples 
vesicles. And by the eighth day of the disease the pocks are fully 
formed. Suppuration commences about the eighth, and continues to 
about the twelfth day of the disease, being attended with swelling of the 
face, and surface generally, and more or less suppurative fever. At 
about the twelfth day suppuration is completed, the pustules being fully 
formed, the swelling of the face and surface generally has subsided, and 
with it the suppurative fever. Desiccation commences about the twelfth 
day. The scabs begin to fall from the face about the fourteenth, being 
generally all off by the twenty-first day of the disease, making the dura- 
tion of the disease from two to three weeks. 

Confluent Small-pox. — The symptoms in confluent small-pox, are 
generally more violent than in the distinct. The pain in the back and 
extremities is more severe, the febrile phenomena are more violent, the 
skin being hot, the thirst urgent, the tongue dry, and covered with a 
dark brown fur, and the nervous system being much more sensibly 
affected. In confluent small-pox, there is a diarrhoea before the eruption 
in many cases, instead of the perspiration which occurs in the distinct ; 
and when this occurs, the secretion of saliva is diminished, instead of 
being increased. 

The appearance of the eruption is more irregular in the confluent, 
sometimes appearing as early as the second, and in other instances, not 
till the fifth day after the commencement of the fever, being frequently 
preceded by a roseolous rash. The pustules of confluent small-pox are 
more numerous, irregular in shape, often running into each other, and 
being less elevated than in the distinct variety. 

The fever only partially subsides on the appearance of the eruption, 
the patient being restless, the thirst urgent, and the skin hot and dry. 
As the disease progresses, the symptoms often become more alarming, and 
frequently a long train of typhoid symptoms are manifested. There is 
great prostration of strength, a dry tongue, low muttering delirium, in- 
voluntary stools, and flow of urine, picking at the bed-clothes ; and the 






VARIOLA. 165 

patient dies about the twelfth day of the disease. Or if the patient 
passes through the suppurative stage, to the period of decline, various 
disorganizing inflammations are liable to occur, such as pleurisy, pneu- 
monia, ophthalmia, &c. ; which may set up a violent symptomatic fever, 
just as the suppurative fever is beginning to decline ; and thus the life of 
the patient becomes again materially endangered. 

The matter, in the confluent pustules, is of a dark brown color ; and 
about the twelfth day of the disease, it begins to escape, and hardens on 
the surface in brown crusts, which fall oif by the fifteenth or twentieth 
day of the disease, leaving deep marks, furrows, or pits, according as 
the disease is more confluent. The eruption of small-pox is not confined 
to the skin, but appears on the mucous membrane of the tongue, throat, 
larynx, and trachea, producing more or less cough ; and very likely in 
other portions of the mucous membranes, as the mucous membrane is 
only a continuation of the skin. 

When small-pox attacks persons in an asthenic state, it sometimes 
manifests a malignant or putrid character, the patient sometimes sinking 
from the direct effect of the morbid poison during the early stage of the 
disease. In these malignant cases, the prostration is such, that there is 
no efficient reaction ; the patient is restless, delirious, or comatose. The 
eruption comes out imperfectly, or suddenly recedes, the perspiration is 
offensive, the face is bloated, and red, or purple, the eyes watery and in- 
flamed ; and in some cases, colliquative diarrhoeas and hemorrhages 
occur before death, which often takes place by the seventh day of the 
disease. In some of these malignant cases, the pustules, instead of con- 
taining purulent matter, are filled with a colorless transparent serum, in- 
dicating the greatest degree of danger ; the secondary fever being gene- 
rally of a typhoid character, or else the patient passing on, rapidly, to 
dissolution. 

Varioloid. — Very mild cases of small-pox are frequently not attended 
with most of the regular phenomena of ordinary small-pox, the attend- 
ing fever being mild, and scarcely attracting attention. The erup- 
tion often appears in clusters, or are very scattering over the surface, 
and occur at irregular intervals between the second and fifth days ; nor 
is it attended with any very marked primary or secondary fever. De- 
siccation may commence earlier than in severe cases, occurring sometimes 
by the eighth or ninth day, and the falling of the scabs by the tenth or 
twelfth. 

The varioloid, however, is only a mild small-pox, rendered so by 
various causes, such as partial protection by previous vaccination, slight 
hereditary predisposition, cleanliness, atmospheric peculiarities, and va- 
rious other accidental causes ; such as prudence, temperance, &c. Such 
mild cases, it should be remembered, depend upon the same cause ; the 
virus generated in the same patient producing in one, distinct ; in an- 
other, confluent ; while in a third, only a mild varioloid disease. 

Such are the ordinary symptoms of small-pox in its various forms, the 
distinct, the confluent, the malignant, and the varioloid. It should be 
remembered, however, that there is a vast variety of modifications in 
these varieties, and that they run into each other, or have no well defined 
dividing line between them. So that, instead of attempting to classify 



166 EXANTHEMATOUS FEVERS. 

cases of small-pox as they occur, it is far better to forget classification, 
names, &c, than to fail of getting at the real condition of the patient. 

Sequelse. — Small-pox, from the derangement it produces in the blood 
and different tissues of the body, is liable to give rise to slow fevers, 
dropsy, a variety of cutaneous affections, ophthalmia, deafness, phthisis, 
paralysis, mania, epilepsy, and a variety of general and local affections. 

Anatomical Characters. — The principal morbid conditions or altera- 
tions found on post-mortem examination are those of the skin and mu- 
cous membranes. There are, however, often found other accidental 
morbid appearances, the result generally of congestion, irritation, or 
inflammation of different tissues and organs, the most frequent of which 
are of the brain, lungs, pleura, &c. There are generally found marks 
of the eruption upon the mucous membrane of the nose, mouth, throat, 
larynx, trachea, and sometimes of the bronchial tubes, and perhaps in 
other parts, as upon the genital organs. 

The alimentary mucous membrane generally shows signs of congestion, 
irritation, or inflammation, and it is said that pustules have been found 
on the mucous membrane of the colon. The seat of the small-pox pus- 
tule is in the vascular structure which lies immediately beneath the 
cuticle ; a slight slough of the true skin, however, occurs, which being 
cast off, gives rise to a depression or pit in the skin. 

Cause. — The cause of small-pox is a specific contagious principle, 
which occurs both under the form of a palpable matter and an imper- 
ceptible effluvium, which is generated in the bodies of patients suffering 
from the disease. 

It is possible that the disease may now be generated spontaneously, as 
at first, or be very much favored by certain epidemic influences, which, 
as I have before said, is the result of the sum total of the imprudence 
of the human family. But it is probable, that while these influences 
may now operate, more or less, as predisposing causes, the specific mor- 
bid poison generated in the bodies of patients suffering from the disease 
is the general, if not the universal exciting cause of small-pox. 

The susceptibility to the impression of the small-pox contagion appears 
to vary in different individuals, not only in relation to the liability of 
becoming affected by it, but also in relation to the degree of violence the 
disease arising from the contagion assumes. — The variolous contagion 
possesses the power of destroying the susceptibility of the system to its 
subsequent operation, so that a second attack of genuine small-pox 
seldom occurs in the same individual. — The contagious principle may 
become attached to various articles of clothing, and retained in a sufficient 
degree of concentration to communicate the disease for a long time. It 
is probable, also, that the disease may be communicated from the bodies 
of patients dead of the disease, and also from the bodies of patients 
suffering from the disease at any time after the establishment of the 
primary fever. 

The period of incubation has been variously estimated, but I believe 
that the time which elapses between exposure to the poison, and the 
establishment of the primary fever, may be set down, as I have said, at 
from eight to fourteen days, at least so far as my observation has 
extended. 



VARIOLA. 167 

Pathology. — There is an ancient tradition, originating I believe with 
the Arabian physicians, that sinall-pox was derived originally from the 
camel, but it is one of the ways in which the human family have ever 
been willing to avoid an acknowledgment of the fact of their own self- 
destruction, either directly or indirectly. As to the precise manner of 
its origin, or the exact nature of the imprudences which first led to the 
generation of this disease in the human system, I presume they may 
never be ascertained, and yet it is as probable that it was the result of im- 
prudence, as it is that the venereal disease resulted from imprudence. 
The same is also true of all contagious diseases, as I have already stated, 
in the early part of this work, and in fact of nearly all diseases, whether 
contagious or non-contagious, there being perhaps not an agent in nature 
capable of injuring or harming man, so long as he obeys the laws of 
his being. This is true, as I have before stated, not only in relation to 
the predisposition to disease, but also of the exciting causes of almost 
every possible variety of disease. 

But in the contagious diseases which we are now about to consider, 
and of which this is one, and which have arisen one after another from 
various imprudences, they have only to be originated once. For the 
virus which is generated in the system during the first attack is sufficient 
to propagate the disease during all time, or till such time as the human 
family shall have so far improved their physical condition, by a return 
to the laws of health, that the susceptibility may be lost. I have made 
this digression here that we may remember that even the contagious dis- 
eases are generally the result, either directly or indirectly, of disobeying 
the laws of health. 

The variolous poison once generated may be received into the system 
through the lungs by respiration, by the application of the matter to 
the unbroken skin or mucous membranes, or by the application of the 
matter to a wound of the skin. In either case the matter entering the 
blood, and affecting first probably the cerebro-spinal and ganglionic 
system, letting down the circulation, and producing a chill. Febrile 
reaction follows, during which the morbid poison being thrown to the 
extreme capillary vessels, produces in the vascular layer of the skin its 
specific effect, leading to the eruption, and also affecting to some extent 
the mucous membranes, especially of the respiratory organs. 

With the eruption the general febrile symptoms usually subside, and 
is only revived by the local irritation set up by the inflammation and 
suppuration of the pustules. The whole process appears to be an effort 
on the part of the system to get rid of a morbid poison it has unfortu- 
nately imbibed, and when it has done this the system is gradually restored 
to health, and the susceptibility to the disease appears to have been lost, 
but failing to eliminate the poison the patient passes on to speedy disso- 
lution. 

Diagnosis. — The difficulty of discriminating between small- pox and 
other febrile affections is confined mainly to the early stage of the dis- 
ease, at which time the possibility of exposure, the severe pain in the 
back, and the unaccountable vomiting, should be taken into consideration, 
and each allowed their due weight in forming what can, at that stage, be 
only a probable diagnosis. After the appearance of the eruption, the 



168 EXANTHEMATOUS FEVERS. 

only diseases with which it is likely to be confounded are measles and 
chicken-pox, but the eruption of measles is generally less prominent 
than in small-pox, and besides, the eruption of measles does not pass on 
to a vesicle and pustule as in small-pox. This process, when it transpires, 
renders the diagnosis plain between measles and small-pox. 

Small-pox may generally be distinguished from chicken-pox by the 
shorter duration of the eruptive fever in chicken-pox, and by the vesicles 
or pustules of chicken-pox not presenting the umbilicated appearance of 
the small-pox pustule. By carefully observing all these peculiarities, 
and taking into account all the circumstances connected with the case, I 
think a mistake need seldom be made, but yet some mild cases of small- 
pox appear precisely like severe chicken-pox, or at least such has been 
the result of my observation in small-pox. 

Prognosis. — In distinct small-pox, in patients of good habits, not given 
to over-eating, or to over-stimulation, the prognosis may be set down as 
favorable, especially if the patient be not terrified by the name. In 
confluent small-pox, however, the danger is always considerable, but if 
there is no hoarseness, and the voice is natural, if the mind is composed, 
and the patient is quiet at night, and between the age of eight and six- 
teen years, and temperate in all things, reasonable hopes may be enter- 
tained of a favorable result of the case. But if the patient be a young 
child, or a person over fifty years of age, and the vesicles are flat and 
the extremities livid, and if there is hoarseness, spitting, and in children 
moaning and grinding of the teeth, or in adults delirium or great 
despondency, little hope need be entertained of a recovery. 

Malignant small-pox is generally rendered so by some hereditary or 
accidental depraved condition of the system, in consequence of which 
the vitality is not sufficient to withstand or eliminate the morbid poison ; 
the patient becomes prostrated, irritable, delirious, and perhaps con- 
vulsed. The eruption fails to appear, or the pustules are imperfectly 
developed, hemorrhages occur, there is great hoarseness, with difficult 
respiration, and finally involuntary stools, and suppression or involuntary 
flow of urine, all of which are unfavorable symptoms, and indicate almost 
certain dissolution. 

Patients may die at any period of the disease, but it appears that more 
cases die during the second week after the appearance of the eruption, 
and the greatest number on the eighth day — at least, such was the result 
of Dr. Gregory's observation in 168 fatal cases which fell under his 
notice in the London small-pox hospital, during the years 1828 and 1829.* 

When small-pox attacks women during pregnancy, death may occur 
at any period — at best, an abortion may be expected, and, very often, 
both the mother and offspring perish. 

Treatment. — As the system laboring under small-pox is evidently 
making an effort to eliminate the morbid poison it has imbibed, the 
danger is from a failure to accomplish this, or else from the over-action 
of the system in this process, in consequence of which, there is too much 
inflammation of the skin, and, perhaps, of other tissues and organs of 
the body. The indications, then, are very plain, and may always suggest 
a rational treatment if we will carefully heed them. 

* See Cyclopedia of Practical Medicine, vol. iii. p. 166. 



VARIOLA. 169 

In those cases in which the febrile reaction is sufficient, and not too 
much, as we do not vet know of any measures that will neutralize the 
poison or arrest the disease, there is but little to be done by the medical 
attendant. The patient should be kept, however, in a moderately cool 
and airy room, allowed the free use of cool acidulated drinks, such as 
lemonade, and be kept on a light and very digestible diet. In such 
regular mild cases, little more than I have suggested need be done. If, 
however, a laxative becomes necessary, half an ounce of the sulphate of 
magnesia may be administered, and, if the skin be dry, two or three 
grains of the James's powder may be given every four or six hours. This 
may fulfill all the indications which arise in such cases. 

But in violent cases, in which there is too much febrile reaction, much 
more may be indicated to prevent a too copious eruption, and also to 
counteract various local inflammations that may arise. In severe cases, 
if the fever runs high, a cathartic of calomel in castor oil will generally 
do very well at first, after which, the bowels may be kept gently loose 
by small doses of the sulphate of magnesia. As a diaphoretic, and to 
allay the general fever, the nitrate of potash, in five grain doses, may 
be given every four or six hours, to be given well diluted in cold water ; 
or, if there is a strong cephalic tendency, the James's powder may be 
given instead in four grain doses every four hours. 

Should local inflammations arise of the brain, lungs, or any other 
part, cups, leeches, &c, may be resorted to, and the local inflammation 
treated according to the indications, always keeping in mind the general 
condition of the patient, as well as the character of the inflammation, 
whether it be of an active or passive character. 

In malignant small-pox, occurring, as it does, in persons of a depraved 
constitution, or in an ansemic state, the system often sinks directly from 
the effects of the morbid poison, and either no eruption appears, or, if it 
does appear, it may suddenly recede, and the patient struggles in a low 
typhus state. In such cases, the system should be sustained by two or three 
grains of the sulphate of quinine, with an equal quantity of camphor, every 
four or six hours, and, if necessary, wine-whey or brandy may be given in 
addition, but such cases, however, often go on to a fatal termination. 

After the eruption makes its appearance, in most cases of small-pox, 
the primary fever in a great degree subsides, requiring generally only 
gentle laxatives, and perhaps a little James's powder, two or three grains, 
with or without a grain or two of camphor, and, in malignant cases, a 
grain or two of quinine. But as suppuration commences, the symptom- 
atic fever arises, being more or less severe, according to the extent of 
the eruption and the amount of suppuration. At this stage, a combina- 
tion of James's and Dover's powders, in three or four grain doses of 
each, every four or six hours, will generally lessen the cephalic tendency, 
promote perspiration, and quiet general nervous irritability, and, if sink- 
ing of the powers of the system occur, the addition of camphor and 
quinine may be indicated. 

Should local inflammations arise during the suppurative fever, cupping, 
leeching, fomentations, &c, should be resorted to, and, if the inflamma- 
tion be of a passive character, quinine, with alterative doses of calomel, 
leptandrin, or podophyllin, may be indicated. The greatest care should 



170 EXANTHEMATOUS FEVERS. 

be taken to keep the inflamed surface as clean as may be ; and the face 
and eyes may be washed often with cold water or milk and water. And 
if the mouth and throat be sore, two drachms of the fluid extract of the 
geranium maculatum may be diluted with an ounce of water, and sweet- 
ened with honey or loaf-sugar, and used as a gargle, with or without a 
little alum or borax. 

To prevent the pustules from affecting the globe of the eyes, pieces of 
folded linen, wet in cold water, may be kept applied to the eyes during 
the eruptive fever. To prevent pits, which are liable to occur on the 
face from the small-pox pustule, something may generally be done. 
Simply opening the pustules when they are completely formed and as 
suppuration is commencing, and pressing out the matter, and washing 
the part with tepid milk and water, will always do some good, and should 
not be neglected if nothing more is attempted. If, however, the pock 
be opened with a lancet as soon as they become vesicular, and a pointed 
piece of the nitrate of silver be applied that and the succeeding day, 
they may not pass on to suppuration, and, consequently, little or no scars 
will be produced. 

The application of the tincture of iodine with a camel hair brush, 
instead of the caustic, will sometimes prevent suppuration, and, conse- 
quently, the formation of pits. Another method, which, in many cases, 
may be preferable to either, is to apply a fine linen cloth, spread over 
with the mercurial plaster, prepared according to the United States Dis- 
pensatory : of mercury, six ounces ; olive oil and resin, of each two 
ounces ; and lead plaster, a pound. This being spread over the fine 
linen, should be laid over the face as soon as the eruption makes its 
appearance, and kept on without intermission for four or five days. In 
either of these ways may the deformity from pitting be greatly lessened, 
and in some cases almost entirely prevented. 

I have said that the patient should be allowed cool drinks, and a light 
digestible diet, but in many cases no solid food can be taken for a time 
at least. In such cases crust-coffee, or toast-water, one-half milk, should 
be allowed till such time as rice and milk, a poached egg and toast may 
be allowed ; or, if the prostration be very great, mutton or chicken 
broth, wine whey, &c, may be indicated. During the whole course the 
greatest possible care should be taken to keep the patient and his clothes 
and bed clothes clean, and to keep the apartments well aired, and during 
desquamation the whole surface of the body should be sponged or 
washed with tepid water. 

And finally, the greatest possible care should be taken in all cases 
that no unnecessary exposure be made, and as the patient leaves his sick 
room, his clothes and bedding should either be destroyed or thoroughly 
cleansed, and the patient, at least once, thoroughly washed from head 
to foot, before he goes forth to mingle with his fellow-men. And 
now, in conclusion, let us remember to keep an eye on the exact condi- 
tion of the small-pox patient, and be sure that we meddle no more than 
the case absolutely requires. 



VACCINA. 171 



SECTION II.— VACCINA— (Cow-pox.) 

By vaccina I mean that variety of exanthematous disease communi- 
cated by inoculation or vaccination, and characterized by the appearance 
of one or more umbilicated vesicles upon the skin, and serving materially 
to destroy the susceptibility of the system to the small-pox contagion. 
The origin of this disease is not quite certain. It has been supposed to 
have originated in the horse, in the disease called grease, and to have 
been communicated by farriers to the teat of the cow, and from the cow 
to the human subject. But it appears to me more probable that it is the 
result of the variolus disease communicated from human beings to the 
cow, and producing in them a modified form of the disease which in man 
has ever been so destructive. The disease having once occurred in the 
cow, whether from the horse or from human beings, may be communi- 
cated to man by application of the matter to a slight wound of the skin, 
and then is communicable from man to man by vaccination. 

It was long ago discovered in Persia, and probably in other parts of 
the world,* that the disease communicated from the cow to man was 
capable of destroying or lessening the susceptibility of the persons so 
affected to the small-pox contagion. But it was in one of the dairy 
counties of England that Dr. Jenner ascertained that persons who had 
suffered from the vaccine disease could not be brought under the influence 
of the small-pox contagion, even by inoculation. He also ascertained 
by experiment that the vaccine disease could be conveyed from one per- 
son to another, and that in every case it appeared to destroy or very 
materially lessen the susceptibility to the small-pox contagion. Dr. 
Jenner published an account of his discoveries in 1798, and though his 
views met with violent opposition, vaccination was soon adopted as a 
prophylactic measure against small-pox in almost every part of the 
w r orld. 

Symptoms. — The symptoms of the disease in the cow are very slight, 
producing, apparently, it is said, a slight febrile excitement, and on the 
fourth day minute pocks appear upon the teats, and perhaps about the 
eyes or nose, which gradually enlarge, assuming the umbilicated appear- 
ance, and becoming perfected and beginning to desiccate about the 
twelfth day of the eruption, 'the sixteenth of the disease. 

To produce the disease in the human subject matter should be taken 
from the pustulate on the teat of the cow, or from a healthy child, in 
which the vaccine disease has previously been produced. It is best 
secured by making slight punctures with the point of a lancet in the 
pustule, about the seventh day after vaccination. The lymph which 
exudes, if not immediately used, being preserved between two pieces of 
glass ; or if the scab is used it may be dissolved in a little water, and 
rubbed down with a knife, and kept in the same manner between glass. 

That part of the arm near the insertion of the deltoid muscle is a very 
convenient place to insert the virus. The insertion I have found most 
conveniently made with two lancets ; with one of which a slight cut is 
made with the point passing under the cuticle, while with the other some 

* See Diet, de Med., xxx. 393. 



172 EXANTHEMATOUS FEVERS. 

of the matter may be inserted in a dissolved state with little or no in- 
convenience. 

About the third day after vaccination a slight inflammation arises at 
the point where the puncture was made, and on the fourth a small pim- 
ple appears, encircled by a faint areola. This pimple now gradually 
enlarges, and on the fifth day assumes a regular circumscribed form, 
with a flattened surface and a small depression at the centre ; the pimple 
having become a vesicle containing a limpid fluid, mostly around the 
edges. 

From the fifth to the ninth day after vaccination the pock gradually 
enlarges, being on the sixth day surrounded at the base by a plain nar- 
row red circle ; on the seventh the vesicle is tolerably well formed, pre- 
senting a shining appearance ; on the eighth the areola increases its cir- 
cumference, till about the ninth or tenth day, at which time the vesicle 
or pustule is perfected ; the pock being from one-third to one-fourth of 
an inch in diameter, one or two lines deep, slightly umbilicated, and 
having a small brown scab or scale in the centre. 

About the fourth day after vaccination there may be a slight febrile 
excitement, and about the tenth day there is often slight pain, irritability 
and restlessness, till the twelfth day, at which time the disease is on the 
decline. By the twelfth day of the eruption, the fifteenth or sixteenth 
from vaccination, the scab is well formed, the matter having become 
purulent and collected in a small cavity on the thirteenth, and the areola 
having faded on the fourteenth day. There remains then by the fifteenth 
or sixteenth day little more of the pock than a yellowish brown scab, 
which gradually dries, becomes more prominent, and falls off during the 
third or fourth week, leaving an oval scar. 

While this is the general course of the vaccine disease, there may be 
wide variations in the symptoms in different cases, the period of incuba- 
tion being greatly lengthened in some cases, and the development of the 
pustule greatly hastened or retarded in others. In some cases there 
may be no perceptible primary fever, and little or no general irritability, 
or even local pain, during the suppurative stage, while in others there 
may be not only a primary fever, but also considerable suppurative fever, 
with great nervous irritability, and severe pain, inflammation, and much 
heat and swelling of the arm. 

If the vaccine virus be inserted at different points, so as to form pocks 
at such distance that their areolae run into each other, the most violent 
and rapid inflammation with gangrene may be the result, as I have wit- 
nessed in several cases, in one of which the patient came near losing his 
arm, and in fact his life. The virus should never be inserted, then, in 
more than one point in the arm, at the same time, unless it be done so 
closely together that but one pock will be produced. 

Vaccination may be practised at almost any age after the third month 
of infancy, and should always be attended to in infancy or early child- 
hood, and should be repeated in after life, once in six or seven years, or 
on the appearance of any very strong prevailing epidemic influence. 
This should be done, as it is possible that the system may lose the im- 
pression, and therefore become susceptible to the small-pox contagion. 

As a general rule, I think it is not advisable to vaccinate females 



VACCINA. 173 

during pregnancy, as serious consequences might result ; but in an 
emergency, where the exposure to small-pox is endangering life, it 
should be done to avoid a worse calamity. In all cases in which the 
unprotected have been exposed to small-pox, vaccination should be im- 
mediately resorted to, with a hope of preventing, or materially modify- 
ing the variolous disease. 

Diagnosis. — To distinguish the vaccine disease from various forms of 
disease produced by vaccination, is of the utmost importance, as without 
this the patient may not know, till it is too late, that he is unprotected. 

No sore, the result of vaccination, should be pronounced as genuine 
vaccine disease, unless it presents all the essential appearances which I 
have laid down, as exhibited by the vaccine pustule. There must be an 
incubation of from two to four days ; then a pimple, which passes on to 
a vesicle by the fifth or sixth day, having an umbilicated surface ; by the 
eighth day a bright areola of greater or less extent should encircle the 
pock, and go on increasing till the tenth or eleventh day, the vesicle 
becoming enlarged and turgid at its circumference. 

The spurious sores differ from the genuine pock, according to my 
observation, in these essential particulars : they frequently arise in 
one or two days after vaccination ; progress rapidly, being more or less 
inflamed ; are irregular in shape ; lack the central depression ; scab 
early, and perhaps re-scab ; are disposed to bleed on a slight injury, 
and, finally, the scar wants those numerous little depressions, so charac- 
teristic of the scar following the genuine vaccine pustule or scab. By 
careful attention to all these peculiarities and differences, a correct diag- 
nosis may generally be formed, so that every person vaccinated may 
know when he has, and when he has not passed through the vaccine dis- 
ease. 

Prognosis. — The prognosis in the vaccine disease is always favorable, 
unless violent inflammation occurs in the arm, followed by gangrene, 
&c, which need not occur, if the virus be inserted in only one point at 
the same time. 

The prognosis, so far as the protection from small-pox is concerned, 
may be set down as favorable under certain qualifications. That is, the 
genuine vaccine disease absolutely destroys the susceptibility to small- 
pox in some cases, and materially lessens or modifies it in every case, so 
that in case small-pox is contracted, it is of a very mild and benignant 
character. 

Treatment. — In healthy children, and in adults of temperate habits, 
no special precautions are necessary on resorting to vaccination, only 
that the patient be of a proper age, and in a good state of health. But 
if the patient be an adult of imprudent habits, given to overeating, 
&c, he should be restricted to a moderate diet, and prudence in every 
respect, and this will generally be sufficient. But in such cases, if a 
primary or secondary fever arise, with swelling, pain, and violent inflam- 
mation of the arm, half an ounce of the sulphate of magnesia should be 
administered, and a solution of the sulphate of iron, two drachms to the 
pint of water, applied to the arm early. 

This will generally arrest the fever and soothe the local inflammation ; 
but if the inflammation passes on to gangrene or suppuration, as I have 



174 EXANTHEMATOUS FEVERS. 

seen, then a warm bread and milk poultice, with or without laudanum, 
should be applied, and the parts freely laid open, for the speedy evacua- 
tion of any matter that may collect. Should mortification occur, with 
general sinking of the powers of the system, the fluid extract of bark, 
quinine, iron, wine whey, &c, should be resorted to. Such cases, how- 
ever, are rare, and form only an exception to a rule, as probably not 
one case in a thousand of the vaccine disease, require any medical treat- 
ment or interference whatever. 

SECTION III.— VARICELLA— ( Chicken-pox.) 

By varicella, or chicken-pox, I mean that mild exanthematous febrile 
affection, so common, in which a slight fever is followed by a vesicular 
eruption, which begins to break, or dry, by the fifth or sixth day. 

Symptoms. — In some cases of chicken-pox, there is a slight febrile 
excitement, preceded, if at all, by a very slight chill, which febrile state 
may continue from a few hours to twenty-four, at which time a vesicular 
eruption makes its appearance, first upon the breast, and gradually ex- 
tends over the body, head, face and extremities. Sometimes there is no 
sensible febrile excitement preceding the eruption, but instead, headache, 
drowsiness, a foul tongue, sickness at the stomach, slight heat of the 
skin, and quickness of the pulse, which continuing perhaps for twenty- 
four hours, the vesicular eruption makes its appearance as in cases 
attended with fever. 

The pocks may appear at first as small red spots, soon becoming 
vesicular, but generally, I think, they appear at first as vesicles, being 
distinct,- irregular in shape, though they may be of an irregular circular 
form, and varying in size from the head of a pin, to that of a split pea. 
The pocks are filled, on their first appearance, with a clear, and gene- 
rally inodorous fluid. 

On the second or third day the vesicles begin to burst, or are broken 
by scratching, and on the fourth or fifth day the fluid in those that 
remain entire, acquires a straw-colored appearance, and gradually dries 
up, leaving crusts, which crumble away gradually, or fall off in scales 
by the eighth or ninth day, without leaving pits, or any permanent 
marks. 

The eruption may be numerous, but generally it is distinct and scat- 
tering. The pustules sometimes appear in successive crops, so that 
when some are just appearing, others are in a state of maturity, and 
others still have dried, and are falling or crumbling away. 

Diagnosis. — Chicken-pox is not liable to be confounded with any dis- 
ease, unless it be mild varioloid affections, from which it generally differs 
in many very essential particulars. In chicken-pox there is very slight 
fever, if any, and it lasts generally but twenty-four or thirty-six hours, 
while in varioloid there is always fever, continuing for two or three days, 
with headache, and sometimes slight delirium, before the appearance of 
the eruption. 

The vesicles of chicken-pox are filled with a white clear fluid, on the 
first day of their appearance, while the varioloid pock is much slower in 
assuming the vesicular character, and has often an umbilicated appear- 



RUBEOLA. 175 

ance. and finally becomes pustular. The vesicles of chicken-pox have 
no central depression, and when punctured they fall to a level with the 
surrounding skin, while in varioloid there is a hardened base, surmounted 
with small circular vesicles containing matter, and generally more or less 
depressed at the centre. 

In varicella there is generally no depression or scar left to mark the 
location of the pocks, while in varioloid there is generally a peculiar pit 
or scar, with minute depressions, at the points where the pocks were 
located. And finally, small-pox is a very contagious disease, while vari- 
cella is only very slightly so. With all these essential differences, vari- 
cella should not generally be confounded with varioloid affections, espe- 
cially if the case be examined with proper care. Cases sometimes occur, 
however, in which it is impossible to decide with certainty at first, or till 
other cases occur. 

Cause. — Varicella may be strongly favored, and perhaps originated, 
by a peculiar epidemic influence, but it is probable that a peculiar con- 
tagion is generally, if not invariably, the exciting cause of chicken-pox. 

One attack of varicella protects the system against a second, but it is 
doubtful whether, under any circumstances, the disease can be propa- 
gated by inoculation. 

Varicella is a disease occurring mostly in children, and is probably 
distinct, in every respect, from any and every possible variety of vario- 
loid or variolous affection. 

Treatment. — Varicella is a disease of so mild a character as to require 
very little or no medical treatment. If, however, the bowels are con- 
stipated, a moderate dose of rhubarb and magnesia, or of leptandrin, 
may be administered, and the patient should be directed to take a plain 
vegetable diet for a few days, and not to be exposed to a cold damp air. 
The skin should be kept clean, and a warm bath or a thorough washing 
should be resorted to after the disease has run its course. 

SECTION IV.— RUBEOLA— {Measles.) 

By rubeola, or measles, I mean that variety of contagious exanthe- 
matous febrile affection characterized by catarrhal symptoms, a peculiar 
rash occurring about the fourth day, the fever and rash generally begin- 
ning to decline about the eighth day of the fever, the fourth day of the 
rash. 

Rubeola is a disease which is highly contagious, and it is probable that 
it may be communicated by inoculation, but it is apt to prevail epidemi- 
cally, and peculiar conditions of the atmosphere appear to modify very 
materially the character of the disease. Measles generally assume a 
mild form during warm and steady weather, while in cold seasons, and 
very changeable weather, they are apt to assume a more violent grade 
or character. The period of incubation may vary from five to fourteen 
days, but seven days is about the usual period in the majority of cases, 
according to my observation. 

Symptoms. — Slight tenderness and redness of the eyes, with an in- 
creased flow of tears, sneezing, cough, and watery discharges from the 
nostrils, together with slight creeping chills and flushes of heat, are 



176 EXANTHEMATOUS FEVERS. 

among the first symptoms of this disease. In some cases the catarrhal 
symptoms precede, while in others they do not appear till the second day 
of the fever. In all cases, however, they appear, and may be regarded 
as specific phenomena of the disease. The cough is at first dry, and 
attended with oppressed breathing, and more or less soreness in the 
fauces, and often considerable hoarseness. The lymphatic glands along 
the neck also sometimes become swelled and tender. 

About the third day considerable nausea and vomiting is apt to occur. 
And, if there be considerable fever, slight delirium may take place on 
the evening of the third clay. And in severe cases, slight coma may 
precede the appearance of the eruption, and in small children convulsions 
are not uncommon at this period, especially if, as is generally the case, 
the fever is of a high grade, the pulse being full, hard and quick, and 
the skin hot and dry. 

Generally about the fourth day the eruption makes its appearance in 
the form of small red spots, apparently papular, at first on the forehead, 
chin, nose and cheeks, and then successively on the neck, breast, body 
and extremities. These red spots soon enlarge, and as they increase 
they run into each other, and form large patches of an irregular or semi- 
lunar shape, leaving intermediate spaces, in which the skin retains its 
natural color. 

During the first day of the eruption there may be discovered a small 
vesicle in the centre of some of the spots. During the second or third 
day of the eruption, the sixth or seventh of the disease, the eruption on 
the face is at its highest state of maturity, at which time there is gene- 
rally heat of the skin and more or less itching. On the next day it 
begins to subside and fade on the face, while on the rest of the body it 
remains quite red. On the face the eruption may be felt with the hand, 
being slightly elevated above the surface of the skin, but on other parts 
the patches are not so sensibly raised. In some severe cases the face 
becomes swelled, and in some instances the tumefaction almost closes 
the eyes. 

The fading and disappearance of the eruption proceeds over the body 
in the same order in which it made its appearance, so that, beginning as 
it does the seventh or eighth day of the disease, it disappears by the 
ninth or tenth day from the commencement of the fever upon the back 
of the hands, where it generally remains longest. About the ninth day 
the eruption assumes a yellowish appearance, and desquamation com- 
mences on the face, which by the eleventh or twelfth day is completed 
over the whole body. 

It should be remembered that the eruption appears about the fourth 
day of the fever, and that both the fever and the eruption go on in- 
creasing till about the eighth day from the commencement of the fever, 
at which time the eruption begins to fade and the fever to subside, both 
having disappeared by the tenth, and desquamation being completed by 
the twelfth day from the commencement of the fever. — The eruption, in 
this disease, is not confined to the surface of the body, but makes its 
appearance in the mouth, and probably more or less in the mucous mem- 
brane of the trachea, bronchia, and alimentary canal. 

The catarrhal symptoms usually subside with the eruption and fever, 



RUBEOLA. 177 

at -which time a slight diarrhoea frequently occurs, which, however, 
should not be regarded as an unfavorable occurrence. Such is the 
general course of this disease, but, like all other diseases, it is liable to 
variations ; even the eruption may appear at any time between the first 
and seventh day of the fever, but on the fourth day more frequently. 

The inflammatory variety of this disease is characterized by a high 
grade of fever, the pulse being full, hard, and tense : the skin dry and 
hot ; the cough violent, harsh, and dry ; there is headache, with occa- 
sional delirium during the night ; the eyes are red ; and the respiration 
oppressed and difficult. Pleuritis, pneumonia, bronchitis, cerebral in- 
flammation and gastro-enteritis, are peculiarly liable to occur in this 
modification of the disease. 

Congestive cases of this disease are characterized by the usual phe- 
nomena of congestion in other febrile affections, the reaction taking 
place slowly, and the system remaining in an oppressed condition. The 
eruption comes out slowly : the extremities are cold ; the features have 
a sunken, anxious appearance : the face is pale ; the pulse feeble ; the 
bowels torpid : and, if the internal congestions are not relieved, coma, 
stupor, or convulsions may occur. 

Malignant cases of measles are liable to occur, but, according to my 
observation, they are exceedingly rare. When measles, however, do 
assume a malignant character, it is generally from some peculiar epidemic 
influence, together with a depraved condition of the system in which 
they occur. The peculiar symptoms of such cases are great prostration ; 
imperfect or irregular appearance of the eruption, it being of a black or 
purple color ; a strong tendency to colliquative diarrhoea and passive 
hemorrhage ; and, finally, all the symptoms which are common to malig- 
nant typhus. 

Sequellx. — The diseases most liable to occur after measles, the result 
of the derangement they produce in the system, are pneumonia, croup, 
ophthalmia, otitis, arachnitis, bronchitis, phthisis, and a general scrofu- 
lous condition of the system. 

Diagnosis. — The only diseases with which measles are liable to be 
confounded are catarrhal fevers, variola, roseola, and scarlatina. A cor- 
rect diagnosis may, however, be formed by attention to the following 
diagnostic symptoms. 

Measles may be distinguished from catarrhal fever by the peculiar 
hoarse cough which is generally present in measles, and also by the 
eruption when it makes its appearance, the diagnosis being presumptive 
at first, and positive after the appearance of the eruption. 

From small-pox measles may be distinguished by the catarrhal symp- 
toms in measles, which do not appear to so great an extent in small-pox ; 
by the eruption in measles being less prominent, and failing to pass on 
to a vesicular and pustular state ; and by the continuance of the fever 
on the appearance of the eruption in measles ; while in small-pox it 
generally either entirely subsides or materially abates. 

From roseola measles may generally be distinguished by the catarrhal 
symptoms in measles, which are not present in roseola. If, however, 
roseola be accidentally associated with catarrh, the extrinsic circum- 
stances should be taken into the account, such as the prevalence or 
12 



178 EXANTHEMATOUS FEVERS. 

not of measles at the time, the liability of exposure, &c, from all of 
which a correct conclusion may generally be drawn. 

From scarlatina measles may generally be distinguished by attention 
to the following facts : 

In measles there are prominent catarrhal symptoms, while in scarlatina 
no such symptoms occur. In measles the eruption consists of vividly 
red spots, united into irregular semi-lunar patches, with the intervening 
skin of a nearly natural appearance, while in scarlatina the redness is 
more diffused and uniform, consisting of an infinite number of minute 
red points united together. The eruption of measles, too, generally 
appears on the fourth day from the commencement of the fever, while 
in scarlatina the eruption usually comes out on the second day, and 
sometimes on the first day of the fever. 

With all these essential differences, if a correct diagnosis be not 
arrived at, I think it must be from a want of due attention. 

Anatomical Characters. — Patients die of measles either from accidental 
local inflammations, from congestion, or from a malignancy, owing either 
to a peculiar epidemic influence, or to an accidental depraved condition 
of the system. When, therefore, the cause of death is local inflamma- 
tion, the post-mortem examination reveals only the marks of that inflam- 
mation. When death has occurred from congestion, the post-mortem 
reveals only the general congested state of the internal tissues and 
organs, and especially of the mucous membranes generally. And when 
death occurs in malignant cases, the peculiar changed appearance of the 
blood is found, which is ordinarily found on examination of subjects 
dead of other malignant affections. 

It will be seen, then, that the anatomical characters of measles have 
no special peculiarities, all depending upon accidental complications 
which arise, and which are the immediate cause of death. 

Causes. — It is probable that certain epidemic influences strongly pre- 
dispose to and perhaps produce measles, but there is no doubt that a 
specific contagion is the general exciting cause of this disease. It is 
asserted, on good authority, that the disease can be produced by inocu- 
lation, blood being taken from the eruptive spots, or lymph from the 
vesicle. 

It is evident that the disease must have been originally produced or 
generated in the human system, like all other contagious diseases, from 
various systems of imprudence ; but the disease once produced, the poison 
is clearly generated in the bodies of persons suffering from the disease, 
and in this way it is kept up, prevailing generally more in winter or cold 
weather. 

Most persons take this disease during childhood, but measles may 
•occur at any age. One attack generally destroys the susceptibility to 
the disease, but, like most other contagious diseases, second attacks 
occasionally occur. 

Prognosis. — Measles generally are not a very dangerous disease unless 
they assume a highly inflammatory, congestive, or malignant character. 
The occurrence of inflammation of the brain, larynx, trachea, or bowels, 
may, in some cases," lead to a fatal termination. Violent congestion, 
occurring early, with tardy or imperfect appearance of the eruption, 



RUBEOLA. 179 

renders the prognosis more or less unfavorable. The same is also true 
in all eases exhibiting marks of malignancy, such as great prostration, 
black or darkish appearance of the eruption, a disposition to passive 
hemorrhages, and other malignant or typhus symptoms. Such cases, 
however, are an exception to the rule, the disease being ordinarily 
attended with little real danger, unless it occurs in females in the puer- 
peral state, or in the latter months of pregnancy. 

Treatment. — As we do not as yet know of any means of arresting this 
disease, the indications are plainly to favor their regular development, 
and to meet any accidental complications that may arise, such as inflam- 
mations, congestions, and any condition arising from a malignant 
tendency. 

In mild cases that assume a regular form, we can do little that will be 
of any avail. The patient should be kept warm, and allowed the free 
use of warm sage tea. If the bowels are confined, a dose of castor oil 
may be given, and to promote perspiration, one-fourth of a grain of 
ipecac may be given in solution ; or, what may be more convenient, from 
five to ten drops of the fluid extract, every four or six hours ; and the 
patient kept on a mild digestible diet. 

But in cases in which there is a high grade of fever, with local inflam- 
mations, an active course of treatment may become necessary. If the 
larynx, trachea, or bronchia be the seat of the inflammation, an emetic 
of ipecac in the early stages may be of very essential service. A cathar- 
tic of the sulphate of magnesia should be administered, and tartar emetic 
in one-sixth of a grain doses every four or six hours. After the violence 
of the inflammation has subsided, the hive syrup in one half-drachm doses, 
every four or six hours should be substituted for the antimony. If the 
inflammation is active or obstinate, cups, sinapisms, &c, may become 
necessary, and should not be neglected. 

If the brain become the seat of the inflammation, a cathartic of calo- 
mel should be administered, and a blister applied to the back of the neck, 
and four grains of the James's powder given every four hours. Cups to 
the back of the neck may be indicated in some cases, and in violent 
cases, general bleeding may be resorted to. 

If the alimentary mucous membrane becomes inflamed, a blister should 
be applied to the epigastrium, and mucilaginous drinks taken, and only 
arrow-root, or some mild, unirritating nourishment allowed. 

In congestive cases, if there is slowness in the appearance of the rash, 
stimulants and tonics may be indicated. Camphor in such cases, in two 
grain doses, made into a mixture with chalk and water constitutes a very 
valuable remedy. 

And if the prostration is very great, from two to four grains of qui- 
nine may be given with each dose of the camphor mixture, and continued 
till reaction is fully established, when the dose of the quinine and camphor 
may be gradually diminished. 

In malignant cases after an emetic of ipecac, a moderate dose of 
hydg. cum creta in castor oil, or podophyllin or leptandrin, may be indi- 
cated, after which wine-whey, camphor, and the fluid extract of bark, or 
quinine should be given, in doses sufficient to sustain, if possible, the 
sinking powers of the system. The patient should also be allowed 



180 EXANTHEMATOUS FEVERS. 

chicken or mutton broths, and if necessary, beef essence. And now in 
conclusion, ]et us bear in mind, that while mild and regular cases require 
little or no treatment, in complicated cases we must be prepared to meet 
promptly any indications that may arise. 

SECTION V.— SCARLATINA— {Scarlet Fever.) 

By scarlatina, or scarlet fever, I mean that peculiar exanthematous 
febrile affection, characterized by sore throat, a scarlet rash appearing 
about the second, and declining about the sixth day, and followed by des- 
quamation ; the disease being liable to various modifications. 

The degrees of modification in the course and symptoms of scarlatina 
are such, that I shall proceed to consider the disease under three heads : 
the simple, the anginose, and the malignant ; the simple embracing those 
mild regular cases, in which there is no marked local complications ; the 
anginose, those in which there are local complications, involving the 
throat ; and the malignant, those in which there is a marked typhous, or 
congestive tendency ; all, however, being only modifications of one and 
the same disease. As a matter of convenience, I will give the general 
symptoms of mild, uncomplicated cases, including, of course, the simple 
variety ; and then I will give the peculiar symptoms of the anginose and 
malignant varieties. 

Symptoms. — Generally after an indefinite period, varying from one 
to three or four days, of ordinary premonitory symptoms of febrile dis- 
ease, the patient has slight chills, followed by flushes of heat, nausea,, 
pain in the back, extremities and head, a hot and dry skin, and gene- 
rally a frequent quick pulse. As these symptoms progress, and gene- 
rally within the first forty-eight hours after the fever commences, a scar- 
let rash or eruption, makes its appearance ; first on the face, and then 
on the neck, trunk, and extremities, spreading finally over the surface of 
the nostrils, mouth, and fauces ; and in some instances, on the tunica 
albuginse of the eye. 

The rash consists of innumerable red points, winch, running into each 
other, give a diffused blush to the skin, leaving generally no intermediate 
skin of its exact natural appearance. In some cases, however, the scar- 
let efflorescence appears only in large irregular blotches, leaving the in- 
termediate portions of skin of its natural appearance. The papilla of 
the skin are generally somewhat enlarged, giving a slight roughness to 
the feel, especially on the breast and extremities. 

Generally with the commencement of the fever, there is slight sore- 
ness of the fauces, with more or less difficulty of swallowing ; and the 
voice usually becomes thick, and more or less unnatural. The face is 
slightly swelled, and the tongue is covered with a white fur, through 
which the enlarged papillae exhibit their scarlet points, the pulse being- 
frequent, quick, tense, and vigorous. 

About the fourth day of the disease, the rash and fever are generally 
at their complete state of development^ and on the fifth day, both begin 
to decline, and continue to diminish till they are entirely gone, about the 
seventh or eighth day, at which time, desquamation of the skin com- 
mences. Usually while the eruption is declining, the tenderness of the 



SCARLATINA. 181 

fauces abates, the perspiration becomes more free, the urine becomes co- 
pious : and in some instances, there is a slight diarrhoea. The fever, as 
we have seen, generally abates as the rash declines ; but in some in- 
stances, the fever abates considerably, as soon as the rash makes its ap- 
pearance, but this is not generally the case according to my observation. 

In some cases, the fever from beginning is so slight, as scarcely to 
attract attention ; while in others, the arterial excitement is very strong. 
Thus we have the ordinary symptoms of simple scarlatina; liable, of 
course, to varjous degrees of febrile excitement, and also to a greater or 
less extent of the rash, but affording no tedious or perplexing complica- 
tions, as in the anginose and malignant cases, which we will now proceed 
to consider. 

Scarlatina anginosa. — In the anginose variety, the fever is generally 
more violent, and the affection of the fauces very marked. In the form- 
ing stage, there is generally considerable headache, nausea, vomiting, 
and general muscular prostration. At the commencement of the fever, 
and in some instances before the fever commences, there is a feeling of 
stiffness of the neck, and more or less swelling and redness of the palate, 
tonsils, uvula ; and, in fact, of the whole fauces. The voice becomes 
hoarse, deglutition difficult, and respiration is attended with a sense of 
constriction in the throat. The fever rises rapidly, the pulse is frequent 
and quick, the thirst is urgent, and the heat of the skin is often more 
intense than in almost any febrile affection. The tongue, too, becomes 
dry ; the injected, or inflamed papillae, projecting from its surface. 
There is generally considerable pain in the head, with much restlessness, 
languor, and prostration, through the whole course of the disease. 

The eruption does not generally make its appearance till the third day 
of the fever, and then is seldom diffused over the whole surface, coming 
out in irregular and large patches, on different parts of the body. It is, 
in fact, no uncommon event for the rash to disappear, for a time, after it 
has made its appearance. If the fever declines on the fourth day, the 
tonsils and palate seldom become ulcerated, the local inflammation sub- 
siding with the fever, without ulceration. But if the fever is active, and 
continues, small ulcers are apt to form about the parts, which may be 
converted into ash-colored superficial sloughs. As the fever subsides, the 
sloughs separate and leave red ulcerated surfaces, which generally cica- 
trize with little difficulty. In some cases, however, the inflammation 
extends into the trachea, and the patient dies with symptoms of acute 
bronchitis. Other local inflammations may also arise, the most frequent 
of which, according to my observation, are of the brain and alimentary 
mucous membrane. 

Scarlatina maligna. — Malignant scarlatina generally begins like the 
preceding, but soon assumes a violent and dangerous character. The 
eruption is irregular in making its appearance, generally coming out be- 
tween the first and fourth days, being pale at first, and acquiring, in most 
cases, a dark livid hue during the progress of the disease ; and in some 
cases, it disappears in parts, and then returns a day or two afterwards. 
The temperature of the skin is variable, and the pulse, active at first, 
becomes small and frequent in the course of the second day. Delirium, 
too, is apt to occur early, and continue more or less during the whole 



182 EXANTHEMATOUS FEVERS. 

course of the disease. The cheeks are suffused with a livid flush, the 
tongue is covered with a dark brown fur, and the breath is generally 
more or less fetid. Gray colored sloughs appear on the palate and ton- 
sils, which soon acquire a dark color ; and if the fever is continued beyond 
the fourth day, the ulcers are converted into dark or black fetid sloughs, 
attended sometimes with the most fearful hemorrhage, especially after 
the supervention of collapse, which not unfrequently occurs by the middle 
of the second week of the disease, or even earlier. 

A fearful case of hemorrhage from the tonsils, uvuU and gums, 
occurred under my observation, a few years since, in the person of a 
young lady laboring under malignant scarlatina. She was the patient 
of my friend Dr. Walter Webb, an eminent physician of Jefferson 
county of this state. I saw the case but once as I was only called in 
consultation ; but the patient, though the hemorrhages occurred often for 
several days, finally recovered, much to the satisfaction of her perse- 
vering and skillful attendant and a large circle of anxious friends. 

Malignant scarlatina may assume an inflammatory, or congestive 
character, or it may partake of the nature of both ; depending upon the 
natural or accidental condition of the patient at the time of attack. 
Thus we have the symptoms of scarlatina as it occurs in its simple, 
anginose and malignant forms, but it must be remembered that there is 
no real definite dividing line between them ; the descriptions being 
designed to answer to all the variations that may occur in this really 
variable disease. 

Sequelw. — Scarlatina is frequently followed by various troublesome 
and dangerous dropsical affections, among which anasarca is by far the 
most frequent, but the serous effusion may be into the cavity of the abdo- 
men, the chest, the pericardium, and even into the ventricles of the brain. 
Yarious nervous affections also sometimes occur as sequelae of the 
disease, as hysteria, asthma, chorea, epilepsy and various other local 
and general neuralgic affections. 

A scrofulous condition with swellings or abscesses of the cervicle 
glands, or about the submaxillary or paroted glands, are, according to 
my observation, a frequent result of scarlatina. Scarlatina also, besides 
leading directly to dropsical, nervous and scrofulous affections, often 
produces a general derangement of the system which strongly predis- 
poses to many acute and chronic complicated diseases. 

Diagnosis. — The difficulty of distinguishing scarlatina from other 
febrile affections, is confined mostly to the first period before the 
appearance of the eruption, during which period the slight redness, and 
perhaps soreness of the fauces, the frequency of the pulse and the 
extrinsic circumstances, go to make a probable diagnosis. When the 
eruption makes its appearance, a positive diagnosis may be formed by a 
careful observation of all the symptoms. 

From measles, it should be remembered, scarlatina may generally be 
distinguished by the following marked differences. In scarlatina the 
eruption generally comes out on the second day of the fever, whereas 
in measles the rash generally appears on the fourth day. The rash in 
scarlatina, appears like a diffused erythematous blush of the skin with 
innumerable points intermixed and small papilla dispersed over the 



SCARLATINA. 183 

cuticle, while the eruption of measles consists of small circular dots of a 
deeper red in the centre than at the circumference, so that, in running 
into each other, the skin presents a less uniform flush than in scarlatina. 
The color of the eruption in scarlatina is scarlet, while in measles 
it is of a darker red inclining to brown. In scarlatina there are no 
marked catarrhal symptoms, while in measles catarrhal symptoms are 
always more or less prominent. And finally in scarlatina the white of 
eye is of a diffused reddish appearance, while in measles the redness is 
generally less diffused. 

From roseola scarlatina may be distinguished by the redness or sore- 
ness of the fauces in scarlatina, while in roseola no such redness or sore- 
ness exists. The red points on the tongue, consisting of enlarged papillae, 
rising through a white coat is a condition not present in roseola, and, 
besides, there is generally much more febrile excitement in scarlatina 
than in roseola. 

Anatomical Characters. — In patients that die early of scarlatina there 
is often nothing found, on examination, to indicate the cause of death, 
and the morbid appearances found on examination of patients dying 
later, which reveal the cause of death, are such as result mainly from 
accidental complications, such as local congestions, inflammations, &c. 

There generally remains, however, after death, more or less redness 
of the fauces, and marks of congestion, irritation, or inflammation of the 
alimentary mucous membrane, as well as a more or less changed condition 
of the blood, it being in some cases thick and in others of a watery 
appearance. The cuticle, in malignant cases, is sometimes found more 
or less separated from the vascular layer of the skin, and the rash is 
generally found of a dark livid appearance— in some cases, however, 
every vestige of the rash disappears at death, so that no trace of it is 
found. 

Cause. — Scarlatina doubtless had its origin in human imprudences of 
various kinds, and when the disease was once produced, the system, 
laboring under it, generates a specific contagion which communicates the 
disease. While, then, a specific contagion, generated in the bodies of 
patients suffering from the disease, is probably the general cause of this 
disease, it is possible that the disease is occasionally produced sponta- 
neously by peculiar atmospheric and personal impurities. This is ren- 
dered probable by the fact that the disease frequently arises under cir- 
cumstances in which it is impossible to account for its origin in any other 
rational way. 

Most persons contract this disease during childhood, but it may occur 
at any age, one attack generally destroying the susceptibility to the 
disease, though second attacks may occur, as in most other contagious, 
exanthematous febrile affections. 

The period of incubation, according to my observation, is about one 
week, and I suspect the disease may be communicated at any time after 
the febrile symptoms are developed, but perhaps not till the eruption 
makes its appearance. 

Pathology. — That a morbid poison enters the blood either by the 
absorbents of the skin, by the lungs, or by the stomach, I believe is 
universally admitted. Now it is probable that this poison, once in the 



184 EXANTHEMATOUS FEVERS. 

blood, passes with it through the system, affecting all the tissues of the 
body, and especially the brain and nervous system. Now, as a conse- 
quence of all this derangement, there is more or less debility and conse- 
quent letting down of the circulation, and hence the slight chilliness 
which occurs. Over-pressure upon the brain and spinal cord leads to 
slight irritation, which, being transmitted to the ganglionic system, reac- 
tion of the heart and arteries follows, and the blood is thrown to the 
extreme capillaries of the vascular structure of the skin, and to the 
mucous membranes, the morbid poison there producing its specific effect, 
especially upon the skin and mucous membrane of the fauces. 

The capillaries of the skin become congested or enlarged, producing 
the blush of the skin, and the papillae of the skin and mucous membrane 
of the tongue and throat becoming enlarged, makes the minute points 
and slight elevations on the skin, and especially the minute red points 
observed on the tongue. Now this deranged condition of the skin and 
mucous membranes interrupts, to a certain extent, the secretion of 
mucus, and to a very great extent the cutaneous exhalation, and hence 
the great liability to dropsical affections after scarlatina, especially as 
perspiration is interrupted, till desquamation is accomplished. 

Prognosis. — The prognosis in simple uncomplicated cases of scarlatina 
is generally favorable, but in anginose and malignant cases there is 
always considerable danger, depending, of course, much upon the nature 
and extent of the complications, and also upon the general condition of 
the system as well as the nature of the prevailing epidemic influence. 

I have known children to die in the early stage evidently from the 
direct effects of the morbid poison upon the brain and nervous system, 
no symptom of reaction having appeared, one instance of which fell 
under my observation during an epidemic which prevailed in Seneca 
county, in a healthy locality between the Seneca and Cayuga lakes, 
during the winter of 1855. I saw the case in consultation with my 
friend, Dr. F. Glauner, an eminent and skillful physician then prac- 
tising in that locality, and though the treatment had been of the most 
judicious character, the morbid poison had done its work, and vitality 
soon became extinct. 

The unfavorable symptoms are a tardy and imperfect appearance of 
the rash, or a sudden retrocession of it ; coma or delirium ; a livid ap- 
pearance of the rash and of the fauces ; petechia, hemorrhages, &c. 

The disease is always attended with the greatest danger when it 
occurs during pregnancy or in the puerperal state. 

Treatment. — As we do not know of any means of neutralizing the 
morbid poison and arresting the disease, the indications are evidently to 
favor its regular development, to control any undue febrile excitement, 
and to correct, as far as may be, any complications that may arise. 

In mild cases of the simple variety of scarlatina, little treatment is 
indicated. The patient should be allowed cool drinks, a little toast-water, 
arrow-root, or other light food, and be kept in a moderately cool room. 
If the bowels are constipated, a dose of castor oil may be administered, 
and, as a diaphoretic, ipecac and camphor in one-fourth grain doses each, 
made into a mixture with prepared chalk and water, may be given every 
four hours during the continuance of the fever. As the fever subsides. 



SCARLATINA. 185 

to produce a slight effect upon the kidneys, and to keep the bowels in a 
moderately relaxed state, from ten to thirty grains of the supertartrate 
of potash may be given in solution in water after each meal. 

In the anginose variety, or in those cases in which the fauces are 
seriously involved, with a high grade of febrile excitement, an emetic of 
ipecac or antimony should be administered at first, after which, a ca- 
thartic of calomel or podophyllin should be given, and a free evacuation 
of the bowels secured. As a diaphoretic, the James's and Dover's 
powders, of each three grains for an adult, every four or six hours may 
be given. 

As a wash for the throat in such cases, a strong sage tea, with alum 
and loaf sugar or honey, will generally do well in the early stages, but 
later, especially in putrid cases, Labarraque's solution of the chloride of 
soda, diluted with eight parts of water, will often do better as a gargle. 
Either, when indicated, may be applied to the throat, or used as a gargle, 
every four or six hours. 

If the skin is very hot and dry, it should be sponged with moderately 
cool water, once every twenty-four hours, generally towards evening of 
each day. Great care should be taken, however, not to apply cold water 
to the surface unless the skin is hot and dry, and no chilliness present, 
as well in this as in all other febrile affections. 

In malignant scarlatina, or in cases in which there is a typhous or 
congestive tendency, it is generally well to give an emetic of ipecac at 
first, and follow that with a cathartic of calomel, rhubard and castor oil, 
or if a mercurial is from any cause contra-indicated, podophyllin or lep- 
tandrin may be given instead. After the operation of a cathartic, and 
when the sinking or congestive character becomes apparent, camphor 
and quinine should be given, in doses for an adult varying from two to 
four grains of each, and continued during the sinking or congested state. 

In cases of mild scarlatina, the patient may be allowed regular meals 
of plain digestible food, such as toast, rice, milk, a poached egg, &c, 
during the whole course of the disease ; but in anginose and malignant 
cases the patient should be allowed toast water, or crust coffee, one half 
milk, taken a little cool if preferred, for a drink, and to sustain the 
system till such time as plain digestible articles of food can be allowed 
or borne. In malignant cases, in which there is great prostration, mut- 
ton or chicken broths, wine whey, and beef essence * may be indicated, 
and should be freely allowed. 

In malignant cases, in which there is hemorrhage from the gums, or 
any other parts, in addition to wine whey, broths, beef essence, and 
quinine, the tincture of muriate of iron, in ten drop doses, may be given 
every four or six hours, alternating with the quinine. In fact, I know 
of no remedy more clearly indicated in malignant hemorrhagic cases of 
scarlatina. It is agreeable to the throat and stomach, affects favorably 
the alimentary mucous membrane, improves the blood, and serves by 
improving the blood and tissues to lessen the hemorrhagic tendency. 

The room of the scarlatina patient should be kept cool, and also well 

* Beef essence is best made by cutting lean beef into fine pieces, and filling or in part 
filling with it a quart bottle ; set the bottle into a kettle of water, and boil two hours ; 
pour off and season. 



186 EXANTHEMATOUS FEVERS. 

aired, so as to be agreeable to the patient, and also that the morbid 
poison emanating from the patient's body may become diluted as much 
as may be, and thus the liability be lessened of communicating the disease 
to others. Every reasonable precaution should be taken to prevent ex- 
posure to scarlatina, but I have little confidence in any prophylactic 
remedy against this disease, such as mercury, belladonna, &c, but should 
rely upon prudence and a strict observance of all the laws of health, as 
a prophylactic against this and all other diseases. 

In the dropsy following scarlatina I have generally succeeded with 
digitalis, squills, and tartar emetic, in moderate doses every four or six 
hours at first, and then substituting the iodide of potassium in five grain 
doses three times per day, keeping the bowels gently open with the 
supertartrate of potash in moderate doses. 

SECTION VI.— ERYSIPELAS. 

By erysipelas I mean that variety of exanthematous febrile affection, 
perhaps slightly contagious, characterized by a diffused eruption or in- 
flammation of the skin, of a superficial or phlegmonous, and sometimes 
malignant character. 

Before proceeding to consider this disease, it is well for us to remember 
the peculiar structure of the skin, and also the fact that the mucous 
membranes are only a continuation of the skin, lining internal parts 
communicating with the skin, secreting mucus to lubricate their surfaces, 
while the skin exhales the perspirable matter. This becomes necessary, 
as the erysipelatous eruption or inflammation often extends over the 
surface of the body more or less, and also into the mucous membranes, 
or it may pass by metastasis directly from the skin to the mucous mem- 
branes, and in fact to the serous and other structures of the body. 

The eruption of erysipelas may consist merely in a congested state of 
the minute vessels, constituting the vascular structure of the skin, usually 
called erythema, or the vascular structure of the skin may become in- 
flamed, constituting what has usually been called simple erysipelas, or 
not only the skin, but the areolar tissue may become inflamed, consti- 
tuting the phlegmonous erysipelas ; and finally, in either case, if there 
is a malignant or typhous tendency, the disease has been called malig- 
nant erysipelas. 

Regarding this disease as an exanthematous febrile affection, I shall 
proceed to consider its symptoms, under the heads of simple, phlegmo- 
nous and malignant erysipelas, as being the most convenient, and inclu- 
ding every possible variety of the disease. 

Symptoms. — Simple erysipelas commences with a general feeling of 
ill health, such as headache, loss of appetite, nausea, general depression, 
foul tongue, and a feeling of weight in the epigastrium. After these 
symptoms have continued for a longer or shorter period, there is more 
prostration with chills, varying from slight chilliness to a severe chill or 
cold stage. 

During the chilly or cold stage there is often headache, nausea, vom- 
iting, &c, but reaction takes place, and gradually febrile symptoms are 
developed, the pulse becomes frequent, the skin hot, the tongue coated, 



ERYSIPELAS. 187 

there is thirst, nausea, restlessness, and in some cases sore throat, and 
slight swelling and tenderness of the lymphatic glands of the neck, 
axilla, or groin, indicating to some extent the point at which the erysip- 
elatous eruption is about to make its appearance. 

If the cervical glands are swelled, the eruption will probably appear 
about the face or scalp ; if the axillary, on the arms or hands ; but if 
the glands of the groin, the erysipelatous eruption or inflammation may 
be expected to appear on the lower extremities ; and finally, if there is 
a general soreness or swelling of the lymphatic glands, the eruption may 
be expected to be very general over the surface of the body. 

At any time after the development of the fever, but generally, I 
think, about the second or third day, the erysipelatous eruption or in- 
flammation makes its appearance, in the form of an irregular blotch or 
stain, which may spread over more or less of the contiguous surface. 
The eruption may be only a congestion of the vascular structure of the 
skin, or a slight inflammation of the skin, and in either case the redness 
will disappear on making pressure on the inflamed or reddened part ; but 
if not only the skin, but the deeper tissues become involved, the redness 
will not disappear on making pressure. 

There is generally more or less burning or stinging pain and tumefac- 
tion, from the beginning, which may increase, more or less, during the 
progress of the disease ; but in simple cases, the swelling is much less 
than in the phlegmonous. Usually about the third day of the inflamma- 
tion or eruption, small vesicles or blisters, of various sizes make their 
appearance, filled with a yellowish serum. In two or three days these 
blisters or vesicles break, and discharge a viscid fluid, which sometimes 
forms crusts or scabs. By the seventh day, from the appearance of the 
inflammation or eruption, and about the tenth day of the disease, the 
crusts or scabs have desquamated, a new cuticle having formed. 

The slight swelling, redness, and febrile symptoms, progress together, 
both in increasing and declining ; so that the fever, the swelling, and 
eruption or inflammation, have all subsided by about the tenth day of 
the disease, when desquamation occurs. It should be remembered, how- 
ever, that there is not always a direct proportion between the fever and 
the eruption, or inflammation ; in some cases there being a high fever, 
with only a slight eruption, and the reverse. 

In some cases, the eruption extends gradually along the skin, without 
increasing much in extent, as it disappears from the parts first affected, 
while it encroaches on the sound skin. The eruption may, in some 
cases, disappear from its original seat, and make its appearance in some 
other, and remote part of the body, as I have often seen. 

The eruption of erysipelas consists, as I have said, in either a conges- 
tion or inflammation of the vascular structure of the skin, and in the 
simple form, the tissues beneath seldom become inflamed to any great 
extent ; but when the inflammation extends deep into the intermuscular 
cellular structures, it constitutes phlegmonous erysipelas. 

Phlegmonous erysipelas. — In phlegmonous erysipelas, as I have already 
intimated, there is, in addition to the eruption or inflammation of the 
skin, more or less inflammation of the intermuscular cellular tissue be- 
neath, the fever is also more violent, the pain much more severe, and 



188 EXANTHEMATOUS FEVERS. 

the swelling greater, than in simple erysipelas. The disease may pro- 
gress, decline, and finally disappear in a few days, like simple erysipelas; 
but it frequently happens, that as the fever diminishes with the local 
pain and redness, the swelling of the part does not diminish in propor- 
tion, it becomes soft, and in a few days matter is formed between the 
muscles underneath the skin. 

In severe cases the matter may extend along the cellular tissue in the 
direction of the muscles, and destroy the adjacent parts, which are fre- 
quently discharged in dirty-looking shreds of mortified substance, mixed 
with pus. And this discharge may continue for weeks, until it com- 
pletely exhausts the patient, or till the system rallies, and the discharge 
finally ceases. 

A remarkable case of this character fell under my care a few years 
since while practicing in Jefferson county of this State. The patient, a 
lady about fifty years old, of delicate health, and a slender constitution; 
had phlegmonous erysipelas affecting the upper portion of the right arm, 
and also the right breast, and whole right side of the chest. The fever 
was of a high grade at first, but the suppurative stage was followed by 
great prostration, requiring full doses of quinine and camphor for several 
days. 

The matter formed in the cellular tissue of the right breast, and also 
in nearly the whole right side of the chest, from near the axilla, almost 
to the floating ribs, and also in the right arm, from the insertion of the 
deltoid muscle to near the elbow. After the system had sufficiently ral- 
lied by the continued use of quinine, camphor, wine whey, broths, &c, 
I made an incision to evacuate the matter from the side, and a pint, or 
more, of thin brownish appearing pus, with shreds of mortified cellular 
tissue, was discharged at first. 

The matter lay between the outer surface of the ribs, and the muscles 
of the side, nearly all of which had been dissected up, more or less, by 
the accumulated matter. The discharge continued for several weeks, and 
also from the arm ; but by the continued use of the iodide of potassium, 
iron, and a nourishing diet, the discharge ceased, and the muscles formed 
new adhesions to the surface of the ribs. The cavity formed by the ex- 
tensive sloughing of the arm gradually healed or filled up, and the lady 
regained her usual state of health. 

I have related this case, as it illustrates severe phlegmonous erysipelas, 
but we must remember that most cases of phlegmonous erysipelas ter- 
minate by resolution, no matter being formed, as I have before stated. 

Malignant erysipelas. — This variety of erysipelas is characterized by 
a putrid typhoid condition of the system, and often tending rapidly to a 
fatal termination. It is sometimes the result of poison animal matter 
taken from the dead body in dissecting, or from putrid sores on the living 
subject ; and in either case, the fever and the local erysipelatous affection 
are of an asthenic, and highly malignant character. 

Malignant erysipelas may, and does sometimes, prevail epidemically ; 
or in particular localities, in a manner to indicate a contagious tendency ; 
or at least that some morbid poison exists in the air, which produces or 
predisposes to it ; while exposure to the disease appears to favor its de- 
velopment, or to act as an exciting cause of the disease. The primary 



ERYSIPELAS. 189 

fever is generally preceded by a marked chill, and is at first of a high 
grade, the skin being hot, the thirst urgent, and there being great rest- 
lessness, and general irritability. The eruption may make its appearance 
at any time after the development of the fever ; or in some cases, a 
slight inflammation may appear to precede it, as in dissection wounds ; 
in either case, it may involve a whole limb, the face, or any other part 
of the surface of the body, of greater or less extent, and have very 
much the appearance of ordinary phlegmonous erysipelas, except that it 
is usually of a darker color. 

Generally between the first and fourth day, the fever rapidly assumes 
a typhoid or typhous character, the pulse becomes small, weak, and fre- 
quent, the eruption or inflamed surface becomes pale, or of a livid ap- 
pearance, and great prostration of the nervous and muscular system fol- 
lows. If the eruption is of the face as the sinking comes on, it frequently 
passes by metastasis to the membranes of the brain, developing all the 
symptoms of acute meningitis. If the eruption is on the extremities, as 
it fades during the sinking, it is frequently translated to the peritoneum, 
or to the mucous membrane of the alimentary canal, developing the or- 
dinary symptoms of peritonitis, or mucous enteritis. If the eruption is 
on the chest, it may pass to the pleura or to the pericardium, developing 
symptoms of acute pleuritis, or of pericarditis, and generally of the most 
rapidly fatal character. 

In some instances I have known the erysipelatous eruption to pass by 
metastasis to the meninges of the spinal cord, producing, in the midst of 
a typhus state, the most violent neuralgic and rheumatic symptoms, 
proving conclusively to my mind, that rheumatism, in some cases at 
least, depends upon an irritated, congested or inflamed condition of 
some portion of the spinal cord or its meninges. 

I have noticed that in cases in which the local erysipelatous affection 
has appeared to pass from the chest to the meninges of the cord, the 
superior portion appears to be the part involved, and the neuralgic and 
rheumatic inflammation is developed in one or both arms ; but if it pass 
from the dorsal or lumbar region, it appears to fall on the - lower portion 
of the spine, and in that case the lower limbs become the seat of the 
neuralgic and rheumatic inflammation. 

I am not aware that this peculiarity of the metastasis of erysipelas to 
the spinal cord, or its meninges, has ever been noticed by any writer, 
but many very marked cases of this character fell under my observation 
during an epidemic which prevailed in the range of my practice, in 
Northern New York, during the winter of 1853 and 1854, a short 
account of which I afterwards published in the Buffalo Medical Journal. 

In malignant erysipelas, if there is no metastasis to internal parts, 
and the patient survives, the eruption or inflammation may terminate 
by resolution and desquamation, by about the tenth day of the disease, 
as occurs in simple erysipelas, and in most cases of phlegmonous ; but 
it often terminates, as in bad cases of phlegmonous, in suppuration or 
gangrene. 

An interesting case of malignant erysipelas, terminating by suppura- 
tion and final recovery, fell under my care in this village, during the 
summer of 1856, in the person of Dr. II. A. Potter, a distinguished and 



190 EXANTHEMATOUS FEVERS. 

eminent surgeon of this village, well known in this country and in 
Europe, as a successful operating surgeon. The facts and history of 
this case I published in the Western Lancet, in the fall of 1856,* from 
which, and my note-book, together with my recollection of the case, I 
draw the following history and symptoms. 

In the early part of July, 1856, Dr. Potter was called on to attend 
his brother, who was also an eminent physician and surgeon, residing in 
Steuben county, of this State, supposed to have been poisoned by matter 
received from an extensive suppurating wound, by a slight scratch in 
one of the fingers of the right hand. The general and local symptoms 
which ware developed in his case, were similar to those usually follow- 
ing dissection wounds, as I understand ; there having been at first a 
slight irritation of the wound, a chill following, and then a high febrile 
reaction, followed by an asthenic malignant erysipelatous eruption or 
inflammation of the arm and side, and great tenderness of the axillary 
glands, general restlessness and irritability, and finally extensive sup- 
puration in the right axillary region. 

He had been bled by his own directions, I believe, before calling his 
brother, a circumstance very much to be regretted, as it probably les- 
sened the chances of his recovery, at least it was so regarded by Dr. 
Potter when he was first called to attend to the case. Dr. H. A. Potter, 
when he was first called to see his brother, regarded his case as a des- 
perate one, and so remained with him up to the time of his death, which 
took place in about one week, thus giving him not only the benefit of a 
judicious treatment, but also of untiring care. 

While Dr. Potter was attending his brother, he opened an extensive 
abscess which had formed in the right axillary region, and passed the 
fingers of his right hand into the cavity, in order to ascertain its direc- 
tion, and also otherwise exposed his hands to the matter which was dis- 
charged in dressing the parts each day. He was, I believe, attending 
another patient with an extensive suppurating wound at the same time, 
or during that week. 

While attending the funeral of his brother, in Yates county, on the 
13th of July, Dr. Potter suffered from a slight uneasiness in a trifling 
scratch, received several days before, on the outside of the third finger 
of the right hand. In a few hours the irritation had passed along the 
lymphatics to the back of the hand, where an asthenic erysipelatous 
inflammation was set up after reaction had taken place, from a chill 
into which he was at that time passing. 

At this time I was called to attend him, he having reached home late 
in the evening. I found him restless, irritable and chilly, notwithstand- 
ing he had taken nearly a quart of whisky in sweetened milk, during 
the preceding eight hours, to counteract the poison, which the Doctor 
knew was producing its general, as well as local effects upon his system. 

A red streak extended from the slight wound on the finger to the back 
of the hand, which was swelled and painful, though no general reaction 
had as yet taken place. The axillary glands were also swelled and ten- 
der, and the general prostration of the system was very great. 

The liquor was continued till something over a quart had been taken, 

* See Western Lancet, vol. xvii. p. 520. 



ERYSIPELAS. 191 

when, as the stomach began to reject it, very little more was given. A 
warm foot bath and friction along the spine, with a strong infusion of 
capsicum in vinegar succeeded, with other measures, in overcoming the 
chilliness and bringing: about reaction, so that no more coldness was ex- 
perienced after three o'clock in the morning. 

As reaction took place, the erysipelatous eruption or inflammation ex- 
tended rapidly up the arm, the whole of which was kept wet with a strong 
solution of the sulphate of iron. A strong infusion of valerian was given 
every six hours up to the third day, at which time nearly the whole ex- 
tremity was swelled to about twice its natural size, and the hand was 
evidently approaching gangrene, to prevent which, I laid it open freely 
between the second and third metacarpal bones. A bloody serous dis- 
charge from the incision relieved the excessive pain in the hand and 
arm, and appeared to arrest the deep asthenic erysipelatous or phlegmo- 
nous inflammation, and, in fact, the progress of the local affection, as 
the color of the arm began to fade, and soon the swelling was evidently 
becoming less. 

At this stage, as there was an evident sinking tendency, I gave him 
the sulphate of quinine, in full doses, with camphor, and applied a bread 
and milk poultice to the hand. This treatment was continued up to the 
seventh day, at which time free suppuration took place in the hand and 
arm ; the matter in the hand escaping from the incision made four 
days before. 

On the eighth day of the disease I opened the arm through the exten- 
sor muscles, two inches above the wrist, and subsequently at a point 
nearer the elbow, and still later made another opening on the ulner side 
of the hand ; from all of which points matter continued to discharge till 
July 30, the seventeenth day of the disease, at w r hich time suppuration 
was suspended, and the cuts were healing by granulation. 

The swelling of the hand and arm was nearly down at this time, but 
the quinine and camphor was continued till August 4, the twenty-sixth 
day of the disease, at which time I discontinued my attendance, the 
hand and arm having healed and only a stiffness remaining. From the 
thirteenth day of the disease, at which time I made the last opening in 
the hand, I gave him five grains of the iodide of potassium three times 
per day, alternating with the quinine, and I believe this was continued 
for about four weeks or about two weeks later than the quinine, and two 
or three weeks after the Doctor was about town. 

The nourishment during the first eight days of the disease was mainly 
toast water or crust coffee, one-half milk, and from the eighth to the 
seventeenth, the period of suppuration, broths, beef essence, &c, were 
taken in addition, and from the seventeenth day onward, toast, eggs, 
wild game, fowls, mutton, beef, &c, were freely served up and taken 
with a good relish. 

The hand for a time, entirely useless, gradually by gentle rubbing 
and careful use was restored to nearly its natural state, and has since 
been well employed by the Dr. in performing some of the most difficult 
and successful operations ever performed in this country.* 

* See American Journal of Medical Sciences for October 1858, page 571, for cases of 
Ovariotomy. 



192 EXANTHEMATOUS FEVERS. 

I have been particular in relating this case, as it illustrates malignant 
erysipelas under a controlling and sustaining course of treatment, while 
the case in Steuben county unfortunately bled, illustrates the rapidly 
fatal tendency of this disease. In other cases it must be remembered, 
the patients may die in the early stage, before the erysipelatous erup- 
tion makes its appearance or even reaction takes place. 

Thus we have the ordinary symptoms of simple, phlegmonous and 
malignant erysipelas, but we must remember that it is an exanthema- 
tous febrile affection, liable like all others to great variations, all of 
which, however, I think may reasonably be brought under these three 
heads, and especially so, if we have the condition of the patient and not 
the name of his disease uppermost in our minds. 

Diagnosis. — The diagnosis in erysipelas before the eruption makes its 
appearance, must be to a certain extent, only probable ; but, by taking 
into account, the prevailing epidemic influence, the tenderness and swell- 
ing of the lymphatic glands, and especially of the neck, the gastric and 
cephalic disturbance, together with the character of the chill, and the 
febrile excitement, this probable diagnosis may be rendered nearly cer- 
tain. But this strong probability is rendered certain, immediately on 
the appearance of the eruption, which we have seen, may appear at any 
time after reaction takes place and fever is developed, but generally 
about the second or third day of the fever, as the eruption differs from 
all others to a degree, not allowing of a doubt even. 

Anatomical Characters. — In cases of erysipelas that prove fatal very 
early, from the direct depressing influence of the morbid poison, as in 
dissection wounds, but little is found to indicate the cause of death, 
except perhaps, a changed or dissolved state of the blood r and a slightly 
brownish or purple appearance marking the seat of the erysipelatous 
eruption. In cases, however, that have progressed, the cuticle is often 
found more or less detached from the vascular structure of the skin, and 
the cellular tissue beneath the skin exhibits more or less marks of inflam- 
mation, according as the disease had been more or less phlegmonous in 
its character. 

In cases in which there has been metastasis of the eruption to internal 
organs, as the brain, lungs, liver, &c, marks of inflammation, with 
collections of pus or serum, are often found to a greater or less extent, 
occupying the organ or part to which the erysipelatous eruption or 
inflammation had been translated. 

Causes. — The exciting causes of erysipelas are various ; such as 
wounds, or any irritant affecting the skin, but general or constitutional 
causes operate to predispose the system to this disease, and often develop 
the disease without any apparent local exciting cause. Taking food 
irregularly, or that which is indigestible or unwholesome, by deteriorat- 
ing the blood, and irritating directly the alimentary mucous membrane, 
is a frequent cause of simple erysipelas. And when we remember, that 
the alimentary mucous membrane, is a continuation of the skin, and that 
there exists a strong sympathy between them, we need not wonder that a 
mucous gastro-enteric irritation, together with a deteriorated state of the 
blood, and the fluids of the body should develop the erysipelatous erup- 
tion or inflammation. 



ERYSIPELAS. 193 

Phlegmonous erysipelas may be produced by the same causes, but, 
generally I think koino-miasmata operating on systems predisposed by 
habits of imprudence, acts as an exciting, and probably also as a predis- 
posing cause of this variety of erysipelas. The paludal poison by 
operating through the blood on the brain and nervous systems produces 
debility, prostration, and generally a chill ; and, if now the skin becomes 
irritated by filth, a cold damp air, or from any other cause, the alimen- 
tary mucous membrane being irritated also, the one or the other will 
become the prominent seat of irritation. 

If now, as febrile reaction occurs, the local irritation be concentrated 
upon the alimentary mucous membrane, gastro-enteritis is the result, 
with perhaps bilious remittent fever; but if from any predisposition or 
accidental cause, the irritation be transmitted to the skin, we have the 
erysipelatous eruption or inflammation instead, complicating the bilious 
derangement, and of course, the attending fever modified according to 
the nature or extent of the local erysipelatous affection. And as in such 
cases, not only the skin, but the adjacent cellular tissues are in a relaxed 
state, the irritation and inflammation is very liable to extend from the 
skin to the intermuscular cellular tissue, producing phlegmonous ery- 
sipelas, and if the intermuscular cellular tissue continue long in an in- 
flamed condition it may terminate in suppuration, and in extensive 
wasting purulent discharge, as we have already seen. 

Now in the prod .ction of malignant erysipelas, all the causes which I 
have enumerated as predisposing to, or exciting, or developing the simple 
and phlegmonous varieties may operate to a certain extent in producing 
the malignant, but I am satisfied that malignant erj^sipelas, whether 
it occur from dissection wounds, or in hospitals, or from an epidemic 
influence is invariably produced by an animal or vegetable poison, or by 
a combination of the two. 

It is probable that a concentrated koino-miasmata may operate alone 
to produce the disease, if the patient be filthy, and confined in bad air, 
so that the system itself becomes the generator of the idio-miasmata 
necessary to produce a dissolved state of the blood, and also the typhus 
condition, as well as the malignant character of the local erysipelatous 
affection. But while the paludal poison may thus operate to produce 
malignant erysipelas, it is probably combined in most cases, with poison, 
animal matter in hospitals, in epidemie influences, and in sporadic cases 
which occur ; and in very many cases, as in dissection wounds, or poison 
animal matter taken from wounds on the living subject, in hospitals, and 
in some epidemic or endemic influences, in filthy localities where human 
beings are congregated ; poison animal matter is alone the exciting 
cause of this disease. 

Thus we have the principal causes of simple, phlegmonous, and malig- 
nant erysipelas, and some of the reasons why each assume their peculiar 
characteristics. 

Pathology. — In relation to the pathology, or nature of erysipelas, it 
appears to me there is room for no reasonable doubt. If we take into 
account the system in a state of health, the causes which operate, and 
the symptoms which are developed, as well as the anatomical characters 

13 



194 EXANTHEMATOUS FEVERS. 

presented in fatal cases, I think we must regard erysipelas as an ex- 
anthernatous febrile affection, liable, of course, to wide variations. 

The causes, whether filth, unwholesome food, marsh, or idio miasmata, 
or even poison animal matter taken directly from the dead or living sub- 
ject, enter the blood either through the stomach, lungs, or skin, being 
taken up by the absorbents, more or less, in either case, passes into the 
blood; affecting, to some extent, the lymphatics, and especially the 
lymphatic glands, causing in them more or less irritation and swelling. 

The morbid poison, in either case, once in the circulation, passes with 
the blood to every part of the system; affecting, more or less, all the 
tissues and organs, but especially the brain and nervous system, pro- 
ducing derangement, prostration, and finally by letting down the circu- 
lation, a chill, more or less, marked. 

During the chill, or cold stage, the cerebro-spinal system becomes 
irritated ; and this irritation being transmitted to the ganglionic system 
produces an irritated action of the heart and arteries, and hence, febrile 
excitement follows, and the blood with whatever morbid poison it may 
contain is thrown to the extreme capillaries in the vascular structure of 
the skin ; and hence, sooner or later, the erysipelatous eruption or in- 
flammation is developed. 

If the morbid poison be only such as are received from unwholesome 
food or drink, and the predisposition be slight, simple erysipelas may be 
the result; but if, in addition to these slight causes, the paludal poison be 
also added, phlegmonous erysipelas may be produced if the patient is 
strongly predisposed ; and finally, if there be added poison animal matter 
in any form, or if only that alone be operating, as in the cases I have re- 
lated, we may have malignant erysipelas of a most rapidly fatal tendency. 
In the simple and phlegmonous cases, if no animal poison be operating, 
it is probable that the blood is not materially changed; but in the 
malignant, and in all cases in which poison animal matter operates as a 
cause, the blood evidently becomes more or less dissolved or changed, 
and hence the typhus symptoms and rapidly fatal tendency of such cases. 

The translation of the eruption to internal parts occurs generally in 
cases in which the general powers of the system are sinking, the metas- 
tasis being to such internal part as happens to be most predisposed, and 
is probably the result of a letting-down of the circulation; the blood, 
together with the morbid poison receding from the vascular structure of 
the skin and surface of the body, and being concentrated upon internal 
parts, and affecting that organ or tissue most predisposed. 

Prognosis. — The prognosis in simple erysipelas is generally favorable 
unless it is translated to some internal tissue or organ, as the meninges 
of the brain or spinal cord, the pleura, pericardium, peritoneum, or to 
the various mucous membranes; in which case ? the danger is always in- 
creased and is greater or less according to the internal parts thus 
involved. In phlegmonous erysipelas the danger of metastasis is, I 
believe, less than in simple cases, but the general febrile excitement and 
derangement of the system is usually much greater, and there is always 
danger of suppuration and a protracted wasting discharge which renders 
the prognosis more unfavorable in the phlegmonous than in simple cases. 
In malignant erysipelas the prognosis is decidedly unfavorable, whether 



ERYSIPELAS. 195 

it occur accidentally, sporadically, or epidemically; the cause generally 
as we have seen being the same, and the disease tending, unless early 
arrested, to a typhus state, and to a fatal termination. 

In middle-aged persons of good habits, the system may endure even 
malignant erysipelas, if the general strength be sustained, as we see in 
the case of Dr. H. A. Potter, but if by accident the patient be bled, or 
not sustained in the early stages, as was the case with his brother in 
Steuben county, the result is almost invariably unfavorable, as it was 
in his case. In very young children, or in persons of advanced age, or 
of filthy intemperate habits, the prognosis is always more unfavorable 
than in middle-aged, temperate, and more cleanly patients, other things 
being equal. 

Treatment. — If we take into account the condition of the patient, and 
the exact deviation from the standard of health, the indications in the 
treatment are very plain. 

In mild cases of simple erysipelas, two or three blue pills may be 
given and followed in six hours by half an ounce of the sulphate of mag- 
nesia, to act gently upon the liver, and to evacuate any irritating mat- 
ters that may be lodged in the alimentary canal. Or if a mercurial is 
from any cause contra-indicated, one or two grains of podophyllin, or a 
drachm of the fluid extract of mandrake, may be given, and followed in 
six hours by the sulphate of magnesia, or castor-oil. 

If a diaphoretic be indicated, three grains of Dover's with an equal 
quantity of James's powder, may be given every six hours, while the 
febrile state continues, and the patient should be kept quiet, and allowed 
a plain, digestible, and moderately nourishing diet. In most mild cases 
this is all that will be indicated, unless the eruption threatens to spread 
to parts in which it might be very inconvenient, or dangerous, as to the 
scalp. In that case, the extension of the cutaneous disease may gene- 
rally be arrested by surrounding the eruption, or making a line on the 
side where it is desirable to arrest its progress, with either the nitrate of 
silver in substance, or a strong solution of it ; or what in most cases is 
better, making a line an inch or more broad with the tincture of iodine, 
with a small brush. The line should be made just at the edge of the 
eruption, so as to extend about one-third of its width over the inflamed 
part, and may be applied each day for as long a time as may be ne- 
cessary. 

If a local application becomes necessary to the eruption, an ointment 
made by mixing two drachms of the sulphate of iron, finely pulverized, 
with an ounce of lard, will do very well ; but if the surface is very hot, 
and the patient complains of severe burning or itching in the part, from 
two to four drachms of the sulphate of iron may be dissolved in half a 
pint of water, and cloths wet in the solution kept applied to the inflamed 
surface, instead of the ointment. 

Mild cases will generally pass on favorably with little more than I 
have suggested, but violent cases, of a bilious character and a strong 
phlegmonous tendency, may require active and persevering -treatment. 
In such cases an emetic of ipecac will occasionally be of service at first, 
in equalizing the circulation and ridding the stomach of any bilious mat- 
ter that may have accumulated; and also strongly tending to promote 



196 EXANTHEMATOUS FEVERS. 

perspiration. After the emetic, when it is indicated, and at first, when 
an emetic is not required, a cathartic of calomel, rhubarb, and castor-oil 
should be administered, and a free operation secured ; after which, the 
bowels should be kept moderately loose, by teaspoonful doses of the sul- 
phate of magnesia, administered once or twice every twenty-four hours. 

As a diaphoretic, four grain doses of the Dover's and an equal quan- 
tity of the James's powder may be combined and given every four or six 
hours, and the sulphate of iron applied as before suggested, and if there 
is a good deal of gastric irritation, a blister may be indicated to the epi- 
gastrium. If, as sometimes happens, suppuration occurs, and the fever 
assumes a typhoid character, the sulphate of quinine, in from two to four 
grain doses, should be given, with the Dover's and James's powders, and 
the system supported by wine-whey, broths, beef-essence, &c, and later, 
by other varieties of plain, digestible and nourishing food. 

If matter collects, it should be evacuated at the most convenient point, 
and a slight compress applied, to secure an adhesion between the differ- 
ent parts of the cavity which has been formed. In this state, if the 
patient be inclined to scrofula, five grains of the iodide of potassium 
should be given three times per day, and continued till after suppuration 
is suspended, when the syrup of the iodide of iron may be substituted, 
in ten drop doses, and continued during convalescence, if necessary, to- 
gether with a good nourishing diet. 

In malignant erysipelas, the prostration during the first or chilly 
stage is very marked, and the patient may die without any febrile re- 
action, from the immediate effects of the morbid poison upon the system, 
as we see in some cases of poison from reptiles, and from the dead and 
living human subject. In such cases, if the patient is seen early, to 
arrest the sinking tendency, diffusible stimulants may be indicated. 
Half a pint of good whisky may be mixed with an equal quantity of 
milk, and sweetened, and a gill administered every two or three hours, 
till it is all taken. This insures reaction, and keeps up the sinking 
powers, till more permanent tonics can be brought to bear in sustaining 
the system. 

If, however, in malignant erysipelas, the patient is not seen thus 
early, and reaction has taken place, the diffusible stimulus should be 
omitted, and a moderate dose of calomel, hydg. cum creta, or leptan- 
drin should be given, in half an ounce of castor oil; and the bowels kept 
open, if necessary, by a teaspoonful occasionally. 

Immediately after the operation of the cathartic, to sustain the system, 
keep up the functions of the body, and promote perspiration ; quinine, 
Dover's, and James's powders, of each three or four grains should be 
given, every four or six hours, during the first two or three days; when, 
if typhoid symptoms make their appearance, the Dover's should be 
omitted, and two or three grains of camphor given with the quinine and 
antimonial powder, instead; and this should be continued during the 
whole course of the disease, the quinine being increased if necessary. 
By commencing with the quinine thus early, the distressing sinking 
which would otherwise occur is frequently prevented, the severity of the 
asthenic erysipelatous inflammation lessened, and also the liability of 
metastasis greatly diminished. 



PURPURA. 197 

In all cases of metastasis of the eruption of erysipelas, to internal 
parts, the local inflammation thus produced, should be treated as ordi- 
nary acute inflammation of the part; taking into account, of course, the 
general condition of the patient. 

In phlegmonous cases, if resolution of the local inflammation cannot 
be secured, and suppuration is tardy, gangrene being threatened, the 
parts involved may be freely laid open, and a poultice applied, in hope 
of securing suppuration. 

Should suppuration take place in malignant cases, the matter should 
be evacuated early, the patient sustained by wine-whey, broths, &c, as 
already directed: and iodide of potassium given, alternating with the 
quinine, during the suppurative stage ; but later, the tincture of muriate 
of iron, in ten drop doses may be given instead; and, in fact, this pre- 
paration of iron may be indicated in the early stages of malignant cases, 
and when it is, should be given alternating with the quinine. Thus we 
have the general principles, to guide us, in the treatment of every pos- 
sible variety of erysipelas that may occur. 

SECTION VII.— PURPURA. 

By purpura, I mean that peculiar exanthematous affection, sometimes 
febrile, and in other cases apparently not; characterized by spots or 
patches of a livid hue on the skin, varying in size from the merest speck, 
only one or two lines in diameter to several inches. 

The eruption consists in a subcutaneous hemorrhage, and may appear 
in malignant typhus, in malignant erysipelas, and various other malig- 
nant diseases, in which the blood is in a more or less dissolved or changed 
state. 

Purpura may, however, occur uncomplicated with any other disease, 
the eruption in some cases being the first intimation of a diseased state; 
but not generally I think, as the ordinary premonitory symptoms' of 
some of the exanthematous febrile affections sometimes precede the erup- 
tion, and generally more or less symptoms of deranged health. The 
disease might be described under two heads, the simple, and the 
hemorrhagic; the difference, however, being merely in degree rather 
than in kind; and, as there is always at least a hemorrhagic tendency, 
with more or less subcutaneous hemorrhage, I shall make no division of 
the disease. 

Symptoms. — The premonitory symptoms of purpura, when closely 
observed, are just what might be expected, if from some cause the blood 
had become suddenly or gradually deteriorated, and the solids materially 
relaxed or changed. The petechia or eruption may make its appearance 
without any marked symptoms preceding or indicating it. But generally 
there is for a time an imperfect or irregular appetite, indigestion, slight 
stupor, and a general languid tendency, restlessness, and irritability, 
indisposition to mental and corporeal exertion, muscular debility, a 
sallow or pale complexion of the countenance, pain in the back, limbs 
and extremities, headache, and sometimes disposition to fainting on 
taking active exercise. 

After these symptoms have continued, or some of them, for a longer 



198 EXANTHEMATOUS FEVERS. 

or shorter period, a slight coldness of the extremities may be experienced, 
and in some cases slight chilliness, or a peculiar sensitiveness to cold 
may be noticed. After this depressed or chilly stage has continued for 
an indefinite time, varying from a few minutes to several days, a slight 
effort at reaction may be noticed, which may in some cases amount to a 
febrile state ; the face having a hectic flush, the pulse being frequent, 
the thirst more or less urgent, and there being a general state of rest- 
lessness and irritability. 

After these symptoms have been developed, when they occur, and at 
first, when no premonitory or febrile symptoms are noticed, the eruption 
makes its appearance, the spots generally appearing first upon the lower 
extremities, and then on the arms, trunk, and perhaps over most of the 
body. The size of the petechise, or spots, varies from the merest speck, 
to several inches in diameter, being irregular in shape, and appearing 
like an ordinary bruise. In young persons, in whom there is often 
slight febrile symptoms, the color of the spots may be at first of a red- 
dish color, but they soon become purple, as they are at first in older pa- 
tients, and such as have no sensible febrile symptoms. The spots gradually 
fade, and may disappear in from five to eight days ; fresh spots having, 
however, made their appearance, so that some are appearing while others 
are fading, till the disease disappears altogether. 

In cases of a strongly hemorrhagic character, small blisters, contain- 
ing blood, often mingle with the dark spots upon the skin, and may also 
be found on the tongue, and perhaps other parts of the mucous mem- 
brane of the mouth and throat, and they probably exist, more or less, 
upon all the mucous membranes. In these cases hemorrhages are liable 
to occur, from the nostrils, mouth, conjunctiva, stomach, bowels, urinary 
passages, and vagina, and sometimes of an alarming character, but gene- 
rally not very copious, it being mostly of a passive nature. Blood is 
also sometimes poured into the brain, lungs, or other vital organs, 
seriously endangering the life of the patient. The blood in such cases 
generally coagulates imperfectly, and is evidently in a reduced and half 
dissolved state. The pulse is weak, the digestive organs more or less 
deranged, and great debility prevails throughout the whole course of the 
disease. 

In some cases of purpura, there are slight elevations of the cuticle, 
similar to those of urticaria ; the eruption, however, may disappear as 
in ordinary cases, fresh spots and elevations appearing while the first 
are subsiding ; the disease continuing three or four weeks, or till the 
blood is restored, as in all other cases of purpura. 

Diagnosis. — The only disease with which purpura is liable to be con- 
founded is scurvy, from which it may be distinguished by the following 
essential differences : 

In purpura there is not that tenderness, softness, and swelling of the 
gums which occur in scurvy. The eruption in purpura is at first of a 
more reddish cast than in scurvy, and besides, purpura usually occurs in 
autumn, when fruits and vegetables are freely used, while scurvy gene- 
rally occurs in the latter part of winter, when little fruit and few vege- 
tables are to be had, and generally very soon disappears if a supply of 
fruits and vegetables can be obtained. 



PURPURA. 199 

Anatomical Characters. — The blood is usually found in a dissolved or 
fluid state, and very generally effused into the different organs and tis- 
sues of the body. It is extravasated blood immediately beneath the 
cuticle, or else in the tissue of the true skin, which constitutes the erup- 
tion or purple spots in this disease. 

Petechias, or purple spots, similar to those of the skin, are found upon 
the mucous membranes, and especially of the alimentary canal, and in 
man}' cases upon the pericardium, pleura, and peritoneum ; and blood is 
found extravasated, more or less, into all the organs and tissues of the 
body. 

Causes. — Purpura may be produced by any cause capable of deterio- 
rating the blood sufficiently to produce the hemorrhagic condition ; 
among the most frequent of which are the putrid fevers, habits of filth, 
impure air, unwholesome articles of food, such as putrid meats, &c, great 
despondency, and frequent fits of anger, intemperance of every kind, 
and finally, various drugs, long continued, which prevent the formation, 
or diminish the proportion of fibrin in the blood. 

Pathology. — The nature of this disease is a little obscure, and yet I 
believe if its symptoms be closely scanned they will be found to indicate 
a pathology that will not totally exclude it from among the exanthema- 
tous febrile affections. The impure air, putrid articles of food, habits 
of filth, &c, which operate to produce this disease, may generate in the 
system itself a morbid poison, of an animal character, which helps mate- 
rially to deteriorate, dissolve, or deprave the blood. 

The system gradually becomes deranged, and sinks down, as in the 
forming stage of fevers : but such is the state of the blood, and conse- 
quent relaxed, and debilitated condition of all the tissues, even the 
muscles, involving of course the heart, that in aged and feeble patients, 
no sensible febrile reaction occurs, and in the middle aged and more ro- 
bust, only a feeble, and slight febrile reaction is produced. During the 
effort at reaction, blood is thrown into the vascular structure of the skin ; 
where, in consequence of its dissolved, or watery state, and the relaxed 
condition of the solid tissues, it is extravasated ; producing the eruption, 
or purple spots, which appear: the same condition also occurring to some 
extent, in all the tissues of the body. 

If the patient be middle aged, and the reaction considerable, the erup- 
tion is free, but the internal hemorrhagic tendency is slight. But if the 
patient is advanced in life, and the effort at reaction slight or impercepti- 
ble, the eruption may be slight ; but the internal hemorrhagic tendency 
is much more considerable ; being liable to occur from all the mucous 
surfaces, as well as into all the tissues and organs of the body. In those 
cases of purpura, in which there are slight elevations of the cuticle, it is 
evidently owing to an enlarged or congested state of the vessels of the 
skin at that point, the blood not being entirely extravasated. Such, it 
appears to me, may be the true pathology of this disease. 

Prognosis. — The prognosis in purpura is generally favorable in young 
or middle aged persons, if the internal hemorrhagic tendency is not very 
considerable; but in patients of advanced age, and of filthy intemperate 
habits; and in cases in which there is little or no apparent reaction ; and 
a strong internal hemorrhagic tendency, the prognosis is always more or 
less unfavorable- 



200 EXANTHEMATOUS FEVERS. 

Treatment. — When we take into account the deteriorated condition of 
the blood ; the relaxed condition of the solid tissues ; the consequent 
hemorrhagic tendency, and the general deranged condition of the system, 
the indications in the treatment of purpura are very plain. Habits of 
filth, intemperance, &c. should at once be corrected, and the patient re- 
stricted to a plain, digestible, and nourishing diet ; taken with regularity : 
and if the bowels are constipated, a full dose of rhubarb or leptandrin 
may be exhibited at first, and the bowels kept regulated if necessary, by 
a pill of aloes and rhubarb, of each one and a half grains, taken at 
evening, if the bowels have not been moved during the day. 

To improve the appetite, favor digestion, and help sustain the system, 
and keep up the circulation, the infusion, tincture, or fluid extract of bark 
should be given in full doses, three times per day, before each meal. To 
change the blood, lessen the hemorrhagic tendency, and help sustain 
the sinking powers of the system, the tincture of muriate of iron should 
be given in ten drop doses after each meal, in a little water, and continued 
till the integrity of the blood, and tone of the solid tissues are fully re- 
stored. Should hemorrhages occur, two grains of tannin, or from half a 
drachm to a drachm of the fluid extract of geranium meculatum, should be 
given every six hours, till the hemorrhage is arrested, 

SECTION Vlir.— GLANDERS— (Equinia.) 

By glanders I mean that malignant exanthematous febrile affection 
contracted by human beings from the horse suffering with glanders, and 
characterised by a muco-purulent and sometimes bloody discharge from 
the nostrils, a peculiar pustular eruption, and by tumors occurring in 
different parts of the body, of either a purulent, bloody, or gangrenous 
character. 

This disease has been recognized in the horse from the time of Hip- 
pocrates, but until a comparatively late period it had not been discovered 
or described as occurring in the human subject, and even now, the dis- 
ease in the human subject is probably of very rare occurrence; no well 
marked case having fallen under my observation. 

Glanders occurs in the human subject under an acute and chronie 
form, the symptoms of which, for the sake of convenience, I will give 
under two heads, that of acute and chronic: 

Symptoms of the aeute. — Acute glanders usually commences with the 
ordinary premonitory symptoms of the exanthematous fevers, such as, 
depression, weariness, languor, pain in the back, and sooner or later, 
slight chilliness, followed by febrile reaction; the pulse becomes fre- 
quent; the skin hot and dry; the thirst urgent, and the tongue more or 
less coated. Usually, about one week after the exposure, and among the 
first symptoms which occur are neuralgic or rheumatic pains, affecting 
the joints of the limbs, and sometimes darting through different parts of 
the body. Portions of skin over the seat of these local pains may be- 
come red or assume an erysipelatous appearance, turning of a darkish 
color, and containing vesicles, or terminating in patches of a gangrenous 
character. 

Usually, in about one week from the commencement of the disease, 
being about the fourteenth day from the time of exposure, a pustular 



GLANDERS. 201 

eruption makes its appearance on different parts of the body, but gene- 
rally most abundant on the face and limbs. 

The pustules vary in size, from that of a pea to two or three times that 
size, and have a slight resemblance to the vaccine vesicle, being some- 
times umbilicated, and having a red areola, being filled with a purulent 
fluid along with coagulable lymph. Generally, along with the eruption, 
small shining tumors appear on different parts of the body, which soon 
turn brown, and may crack and discharge an acrid thin serous fluid, or 
they may mortify or form connections with abscesses in the intermuscu- 
lar structures. 

The pustular eruption in this disease appears in successive crops, so 
that some are appearing while others are maturing at the same stage of 
the disease. Neither is the eruption confined to the surface of the body, 
but appears on the mucous membrane of the nose, mouth, fauces, larynx, 
and it is said, upon the alimentary mucous membrane. In some cases, 
at the very commencement, of the disease, but generally after the erup- 
tion makes its appearance, a muco-purulent fluid begins to be discharged 
from the nose; being at first yellowish, but later having a bloody appear- 
ance and an extremely offensive smell, and excoriating the parts with 
which it comes in contact. Some of this matter passes along the 
posterior nares to the fauces; which, with the mouth, larynx, lips, eye- 
lids, forehead, and in fact the whole face becomes red, inflamed, and 
often very much swelled, closing the eyes and materially distorting or 
mutilating the features. 

As these severe local symptoms are developed, the skin becomes hot, 
the tongue more dry, the respiration difficult, the pulse frequent and 
feeble; and there is generally thirst and an offensive colliquative diar- 
rhoea. Finally a fetid odor exhales from the body, the mind becomes 
unsteady, coma or delerium occurring; and by the end of the second or 
during the third week the patient sinks into extreme prostration, through 
which, with involuntary discharges, the miserable sufferer passes on to 
speedy dissolution. 

The acute form of the disease does not always present precisely these 
symptoms, being liable, of course, like all other diseases, to variations. 
In some cases, the nasal symptoms predominate from the first, while in 
others the nasal discharge may not occur till the latter stage of the dis- 
ease; the carbunculous and eruptive tendency being by far the most 
prominent feature. 

Chronic Glanders. — The symptoms of chronic glanders differ consi- 
derably from those developed in acute cases. 

In the mildest cases no febrile symptoms are noticed at first, the dis- 
charge of an offensive, purulent, or senious matter from the nose being 
the first indication of the disease. Such cases may pass on for months 
and finally recover, or acute symptoms may occur, with malignant 
tumors, or abscesses, and a fatal termination be the result. 

Generally, however, in chronic cases, slight neuralgic or rheumatic 
symptoms may occur, with more or less redness of the surface at the 
seat of the pain, and perhaps slight febrile symptoms may be developed, 
and continue for a longer or shorter time. At an indefinite period of 
the disease the nasal discharge may make its appearance, and, together 



202 EXANTHEMATOUS FEVERS. 

with suppurating tumours, in different parts of the body, may pass on 
for months, and perhaps recover, but more probably, go on to a fatal 
termination. 

Diagnosis. — The only disease with which glanders would be likely to 
be confounded, is acute or chronic catarrh, of the schniderian membrane, 
occurring in its worst form, and being complicated, as it often is, with 
chronic neuralgic or rheumatic symptoms. 

In glanders, however, the nasal discharge is of a muco-purulent, and 
perhaps bloody character, while in simple catarrh of the schniderian 
membrane, the discharge is less acrid, wants the offensive odor, and is 
generally of a thin mucous character. 

In the neuralgic or rheumatic localities in glanders, more or less swel- 
ling and redness appear, which is not generally the case in simple 
catarrh; and, finally, the presence or absence of the eruption, the 
abscesses, and the febrile symptoms, together with the general condition 
of the patient, and the possibility of exposure, will generally render the 
diagnosis clear, between glanders and simple catarrh of the schniderian 
membrane. 

Anatomical Characters. — On post-mortem examination, besides the 
external lesions, there is found numerous small white pustules, inter- 
spersed with patches of ulceration on the mucous membrane lining the 
nasal cavities. The septum nasi is always more or less ulcerated, and 
often perforated, and the nostrils and frontal sinuses contain a viscid 
mucus. 

On laying open the gangrenous tumours, the muscles are of a dark 
color, and appear to be more or less decomposed. They emit an offen- 
sive odor, and contain more or less purulent matter, either in small 
specks, or infiltrated through their structures. 

White pustular eruptions, similar to those in the nasal cavities, are 
generally found in the soft palate and fauces, and sometimes in the ali- 
mentary mucous membrane. Large abscesses are found between the 
muscles, and in some cases pus is found in the articulations. 

Cause. — Glanders, in the human subject, arises from a morbid poison, 
generated probably in the horse, and communicated either by contact of 
the poison with an abraded surface, or else through the stomach or 
lungs. When the matter is introduced into the system, through an 
abrasion of the skin, it affects the lymphatics very much like the animal 
poison received in dissection from the human subject, and there is a 
striking similarity in many respects between the diseases which the two 
poisons produce. 

While glanders is generally taken from the horse, it is probable that 
the disease may be communicated from man to man, and that the pre- 
disposition to the disease is much stronger in persons of filthy intem- 
perate habits than in the strictly temperate and cleanly, as is the case 
with almost all contagious and noncontagious diseases. 

Nature. — That the morbid poison which produces this disease operates 
upon the system, in many respects, like the poison received from the 
dead human subject, is evident from the symptoms which are developed. 
In glanders, however, the poison may be received through the stomach, 
and probably the respiratory passages, and this may account in part for 



DENGNE. 203 

the nasal affection in this disease, and also for that of the mouth, fauces, 
&c, which do not occur from dissection wounds. 

Prognosis. — The prognosis in glanders, as we have already seen, is 
always unfavorable, and jet it is possible that in mild cases of the dis- 
ease patients sometimes recover. 

Treatment. — From the morbid condition in acute glanders, it appears 
that an emetic at first, followed by a mercurial cathartic, may be indi- 
cated, and afterwards quinine, and perhaps the iodide of potassium. 

In chronic cases, in which the nasal discharge is the prominent symp- 
tom, it appears to me that the iodide of potassium, in five grain doses, 
three times per day, continued for several weeks, and then, followed by 
the syrup of the iodide of iron, for a long time, might be of service. As 
a local application to the schniderian membrane, I would use a solution 
of corrosive sublimate of the strength of half a grain to the ounce of 
water, snuffed up the nose once each day. 

SECTION IX.— DENGNE— [Dandy Fever.) 

By dengne , or dandy fever, has been designated a peculiar exanthema- 
tons febrile affection, characterized by a high fever, violent rheumatic or 
neuralgic pains in different parts of the body, and by a rash or an erup- 
tion of either a papular, vesicular, or pustular character. 

This disease appears to have prevailed epidemically, in all its visitations, 
having appeared in Philadelphia in 1780 ; in Calcutta in 1824, and in 
the West Indies in 1827, from whence it extended to New Orleans, 
Charleston and Savannah, in the summer and autumn of 1828. The 
term dengne is supposed to be, according to Prof. Wood* " a Spanish 
corruption of the word dandy ; the name of dandy fever having been 
jocosely conferred on the disease by the negroes of St. Thomas, from the 
stiff carriage of those affected with it." 

Since 1828, the disease appears to have prevailed, according to Prof. 
Dicksonf "in Mobile in 1844, and in Natches in 1848," and also in 
Savannah, and finally more or less along the " southern seacoast," till 
1850, at w r hich time, an epidemic of considerable severity again visited 
Charleston, an interesting account of which is furnished by Prof. Dickson, 
in his "Elements of Medicine." 

As dengne has never prevailed within the range of my practice, I shall 
attempt only a general description of the disease, leaving the reader to 
search out the minutia in the able accounts which have been furnished by 
eminent physicians, practicing in localities where the disease has prevailed. 

Symptoms. — The symptoms of this disease, according to Prof. Dickson's 
account, are very similar in the first stages, to those occurring in cases of 
epidemic rheumatic fevers, which occasionally prevail in our climate ; a 
short account of an epidemic of which I furnished for the Buffalo Medical 
Journal of 1855. The disease commences with pain, more or less stiff- 
ness of the neck, back, and loins, and slight swelling of the muscles of 
the limbs, and of more or less of the joints. There is also slight intoler- 
ance of light, restlessness, and more or less chilliness, followed by fever, 

* See Wood's Practice, vol. 1, page 458. 

f See Dickson's Practice of Medicine, page 734. 



204 EXANTHEMATOUS FEVERS. 

headache, redness of the eyes ; a full, frequent, and quick pulse ; a hot 
and dry skin, with a more or less urgent thirst. The fever usually de- 
clines on the second or third clay, leaving only slight swellings of the 
lymphatic glands of the neck, axilla and groin, which had taken place 
during the initial fever, and slight rheumatic symptoms, with general 
debility. 

After an interval of two or three days, there is a return of the fever, 
and an increase of the neuralgic, or rheumatic pains, the tongue becomes 
coated of a yellowish color, the stomach irritable, and the patient de- 
jected and fretful. Vomiting also occurs, with great lassitude and 
restlessness. On the fifth or sixth day of the disease, an eruption makes 
its appearance, attended with more or less relief of all the distressing 
symptoms. The eruption is sometimes continuous as in scarlatina ; in 
other cases it is in darkish patches, as in measles, while in other cases still, it 
is " either papular, vesicular, or pustular," and in some cases, a mixture 
of all these forms, or it may present an erysipelatous appearance. 

The rash or eruption makes its appearance first on the face, and then 
gradually on the body and extremities, and when fully developed, is at- 
tended with an itching or burning sensation, and sometimes with a 
secondary fever, and a return or increase of the rheumatic pains. 

The eruption disappears after two or three days ; the color of the skin 
gradually fading, with slight desquamation of the cuticle. But the af- 
fection of the joints may continue more or less troublesome for several 
weeks ; the patients remaining weak, or depressed in body and mind. 

The duration of the disease is about eight days, and it attacks equally 
all ages, and in some localities where it has prevailed, almost the whole 
population have been affected by it ; but generally, nearly or quite all 
have recovered from it. The inflammation of the lymphatic glands of 
the neck, axilla, and groin, continues in some cases after convalescence 
is established, and in some cases the tumors have suppurated. 

Diagnosis. — As dengne always prevails epidemically, little difficulty 
attends its diagnosis; except, perhaps in the first cases which occur, 
which might be mistaken for measles, scarlatina, or yellow fever. 

From measles it may be distinguished by the want of catarrhal symp- 
toms, which invariably attend that disease. From scarlatina it differs in 
the time of the appearance of the eruption, it generally coming out later 
in dengne than in scarlatina; and from both scarlatina and measles it 
differs widely in its neuralgic or rheumatic symptoms, which do not pre- 
vail in those diseases. From yellow fever it differs in not presenting the 
yellow appearance of the skin, which is an attendant on that disease, and 
also in the fact that yellow fever is often a very fatal disease, while 
dengne is seldom or never so. 

Cause. — Dengne is an epidemic, and probably contagious disease, but 
the exact nature of the cause is as yet entirely unknown. An epidemic 
of this disease differs from many others, in nearly the whole population 
being affected by it; in this respect partaking of the peculiarity of in- 
fluenza. The period of incubation is supposed to vary from one or two, 
to ten days. 

Pathology. — From the symptoms which are developed in this affection, 
and from their similarity in many respects to epidemic rheumatic fevers, 



DENGNE. ZUQ 

which have occurred under my observation, I am disposed to regard 
dengne as an exanthematous febrile affection, of a rheumatic character. 

The morbid poison, whatever it may be, on entering the blood may 
affect at an early stage the cerebro-spinal system or their meninges, either 
directly or by the congestion the forming or chilly stage produces; and 
this may account for the rheumatic character of the disease. As reaction 
is fully established, the blood, with its morbid influence is carried to the 
minute capillaries in the vascular structure of the skin, where irritation 
and an eruption is the result. This eruption on the skin may act as a 
counter irritant to the cerebro-spinal system or their meninges; and 
hence the great palliation of the symptoms which occur as the eruption 
makes its appearance. 

The swelling and irritation of the lymphatic glands probably arises 
from the morbid febrific agent in its passage through them, as it is 
carried along the lymphatics, as more or less of it would be in this 
disease. 

Prognosis. — The prognosis in dengne, it appears, is always favorable, 
so far as recovery is concerned ; as in the few fatal cases which have 
occurred, it appears to have been from accidental complications. The 
prognosis, in so far as it relates to the probability of an attack, when an 
epidemic is prevailing, may be set down as unfavorable, as nearly the 
whole population are likely to be affected by it. 

Treatment. — From the morbid condition, in this disease, the indica- 
tions appear to be very plain, as I have found them in epidemic rheu- 
matic fever, to equalize the circulation, promote perspiration, and to sus- 
tain the system; meeting, of course, any complications which may arise. 

To equalize the circulation and promote perspiration, the warm foot 
bath and warm sage tea are clearly indicated. The warm foot bath 
might be used morning and evening for two or three days, and the warm 
sage tea used freely as a drink at all hours, with or without milk, as the 
patient might be able or not to take solid food at regular meals. If the 
bowels are constipated, a mild cathartic of rhubarb or leptanclrin, in 
castor oil, might be indicated, but not otherwise I think. 

To sustain the system, quiet nervous irritability and promote perspira- 
tion, it appears to me that quinine, Dover's and James's powders are 
clearly indicated. Four or five grains of Dover's, with two or three 
grains each of quinine and James's powder may be combined and given 
every six hours, as I have done, with the most happy effects in our 
epidemic rheumatic fevers. 

Should the rheumatic symptoms predominate or require any attention, 
I think the iodide of potassium, in five grain doses, three times per day, 
alternating with the quinine, or given before each meal, after the qui- 
nine is no longer indicated, would be found to speedily and permanently 
remove the rheumatic symptoms and materially favor convalescence. 

I offer these suggestions in relation to the treatment of dengne with 
more confidence, having treated on this plan very many cases of a rheu- 
matic fever, which prevailed epidemically, in the range of my practice in 
the winter of 1853 and 1854. In that epidemic there was a chill, febrile 
reaction, an erysipelatous eruption, and more or less rheumatic compli- 
cations. 



CHAPTER VI. 
GENERAL INFLAMMATORY DISEASES 



SECTION I.— ACUTE RHEUMATISM. 

By rheumatism I mean a peculiar general inflammatory disease, liable 
to affect any organ or tissue of the body, but more generally locating in 
the fibrous and muscular structures, from which, however, it is very liable 
to pass by metastasis, or extension, to other tissues, and to internal 
organs. 

As the fibrous and muscular tissues, or structures, are the parts most 
frequently involved in, and peculiarly predisposed to rheumatic inflamma- 
tion, it follows, that when rheumatism becomes seated in any organ which 
is composed in part of muscular or fibrous tissue, these structures become 
the immediate seat of the disease, but not necessarily the exclusive seat. 

Rheumatism in all its forms is generally immediately preceded by neu- 
ralgic pain and irritation, which neuralgic pain or irritation I have gene- 
rally been able to trace to an irritation, or else congestion, of that part 
of the brain or spinal cord supplying nerves to the part. This peculiar 
irritation of the brain, or spine, which produces acute rheumatic inflam- 
mation, I believe may be either irritation, inflammation, or congestion, 
but probably in most cases there is congestion. Now this congestion may 
be the result of any cause which deranges the flow of the nervous influ- 
ence and disturbs the circulation, such as retained perspirable matter, 
bilious derangement, or any other irritating cause, acting through the 
blood on the cerebrospinal and nervous system. 

Symptoms. — There is generally a dull pain in the head* or back, or 
more frequently of both, for a time, after which there follows chills, 
more or less severe, alternating with flushes of heat, with general lassi- 
tude, loss of appetite and depression of spirits. At this stage there are 
darting pains in the principal nerves which supply the limbs or part, 
which are to become the seat of the rheumatic inflammation. And I 
have generally noticed that the rheumatic inflammation locates, in most 
cases, in the limbs or parts which receive their nerves from that part of 
the brain or spinal cord in which the congestion, irritation, or pain, is 
first felt. If the early pain, congestion or heaviness is in that portion 
of the spine which furnish the brachial nerves, the neuralgic pain and 
the succeeding rheumatic inflammation will generally be, according to 
my observation, in the superior extremities or arms. 

If, however, the early irritation, congestion or heaviness, be lower in 
the spine, as at the point which gives off nerves to supply the lower ex- 
tremities, the neuralgic pains and the succeeding rheumatic inflammation 
will generally be found, I think, to occur in the lower extremities. And 



ACUTE RHEUMATISM. 207 

the same is true, I am satisfied by careful observation, in all other points, 
in the brain and spinal cord. And in cases in which there is no sensible 
heaviness even, experienced at any point in the brain, or along the spine, 
I am confident from the effects of cupping, in such cases, that there is 
more or less congestion acting as the direct cause of the neuralgic pain, 
and subsequent rheumatic inflammation. 

After the chill, during which the local and general cerebro-spinal con- 
gestion is greatly increased, and the neuralgic pain severe, there is de- 
veloped a general febrile excitement, and very soon a local rheumatic in- 
flammation. In some cases the febrile reaction becomes completely 
established before the local rheumatic inflammation is set up ; but in 
other instances the local inflammation is developed before the general 
febrile reaction takes place. 

Now I suspect that the neuralgic pain in the limb, or part, produces 
an irritation in the capillaries of all the tissues, but more especially in 
the fibrous or muscular tissues involved, on account perhaps of the firm- 
ness of their structure, and hence the rheumatic inflammation which fol- 
lows. Perhaps another reason why the fibrous or muscular structures 
are more liable to rheumatic inflammation than any other tissues, is 
the fact of their being more abundantly supplied with nerves of sensa- 
tion and motion, and also the fact that the nerves in dense, firm tissues 
become vastly more irritated, from slight congestion of the capillaries, 
than in looser tissues, which might tend to develop rheumatic inflam- 
mation. This appears the more probable when we reflect that the looser 
the tissue, the less liable it is to become the seat of rheumatism ; for the 
firm serous membranes are vastly more liable to rheumatic inflammation 
than the less firm and loose mucous or cellular structures. 

The parts affected by rheumatic inflammation are generally swelled, 
and extremely painful, the slightest pressure or motion causing the 
greatest degree of suffering. And this is not so strange when we re- 
member the firmness and density of the structures involved. Sometimes, 
if the patient be kept perfectly at rest, some abatement of the severe 
gnawing pain is experienced during the day ; but at night, as the exha- 
lations from the skin grow less, by the influence of cool damp air, in- 
tense exacerbations take place. 

Whether the fever precede or follow the development of the local 
inflammation, it generally acquires additional violence, as soon as the 
local affection is fully established. The pulse becomes full, frequent and 
vigorous; the skin hot and dry ; the tongue coated with a white fur, 
changing to a brown color as the disease advances ; the thirst is urgent ; 
the bowels constipated; and the urine scanty, and of a reddish color. 
In very severe cases of rheumatism, headache, and slight delirium 
attend during the exacerbations. 

Rheumatic inflammation may pass by metastasis, or extend to internal 
and vital parts; the most frequent point, perhaps, is to the heart and its 
lining and investing membranes. If the pericardium or endocardium 
become involved, there is oppression in the region of the heart; hurried 
and difficult breathing, palpitation, frequent pulse, and a disturbed and 
anxious expression of the countenance. 

If the muscular structure of the heart itself become involved, as hap- 



208 GENERAL INFLAMMATORY DISEASES. 

pened in one fatal case under my care, there is in addition to the symp- 
toms enumerated above, the most distressing pain in the heart, appa- 
rently increased by its own action, so that its pulsations or contractions 
at times will almost cease, the countenance becoming livid, the extremi- 
ties cold ; and the patient for a time enduring the most distressing faint- 
ings, sinking, &c, passes on to speedy dissolution. In this case, I am 
satisfied that dearth occurred from an inability on the part of the heart 
muscle to carry on the circulation, in part perhaps by the morbid 
changes in its structure, and also in part from the violent pain its own 
action produced, both operating together to suspend its function entirely. 
Anatomical Characters. — The blood contains an unusual amount or 
proportion of fibrin in this disease, sometimes amounting to nearly or 
quite ten parts to the one thousand, the healthy standard being about 
three. In relation to the quantity of uric acid in the blood, it is doubt- 
ful if more exists, as a general rule, than in health. 

On post-mortem examination, the synovial membranes are found 
thickened and red, and generally an increased amount of liquid is found 
in their cavities, and very rarely pus, false membranes, &c. Signs of 
inflammation are exhibited in some cases, by softening of the fibro- 
cartilages, and of the muscles, and signs of inflammation are sometimes 
presented by the lining membrane of the arteries. In cases in which 
the heart is involved, various morbid appearances are presented, accord- 
ing to the time the disease has progressed. In one case, I found the 
pericardium very much thickened, and firmly united to the heartland 
the valves thickened, and rendered nearly incapable of acting, from 
appearances at least. 

Causes. — If, as I have supposed, the causes of rheumatism act through 
the blood on the cerebro-spinal system and their nerves, any cause 
capable of producing debility, congestion, or irritation of the brain, or 
spinal cord, may produce rheumatism. Among these causes, retained 
perspirable matter, being an irritant, may produce rheumatic inflamma- 
tion, or that condition of the system which develops it. Hence cold, 
with moisture, or atmospheric vicissitudes, is one of the most frequent 
causes of this disease. This accounts for its occurring most frequently 
in damp and variable seasons of the year, and also for its being aggra- 
vated during the night time when it does exist. 

The paludal poison, by the debility or prostration it produces in the 
cerebro-spinal system, and the functional derangement which follows, 
may produce acute rheumatism, many marked cases of which have fallen 
under my observation during the past few years, and some complicating 
severe bilious fevers. The sudden suppression of a gonorrhoea, by throw- 
ing into the blood a poisonous principle, may so far affect the brain and 
nervous system as to develop acute rheumatism. 

It is probable also, that very many other morbid agents, may, by 
acting through the blood on the cerebro-spinal s}^stem, to produce acute 
rheumatism. It is probable also, that in a highly sthenic constitution, a 
high electrical state of the atsmosphere may act as an exciting cause of 
acute rheumatism, while in debilitated, or asthenic constitutions, it is 
probable that an opposite, or low electrical state of the atmosphere, may 
produce this disease, by taking off the already too scanty supply of 
electricity from the system. 



ACUTE RHEUMATISM. 209 

Now I am satisfied that any one, or all these causes, may act to pro- 
duce the debility, congestion, or irritation of the brain or spinal cord, 
which is necessary for the development of acute rheumatism ; while the 
precise seat of the inflammation, will depend upon the natural or acci- 
dental point of irritation, in the cerebro-spinal system, as I have before 
suggested. If the brain, from hereditary or accidental causes, is more 
irritable than any point in the spine ; there will be rheumatism of the 
fibrous structures of the brain, or its meninges, or of some muscular or 
fibrous structure about the head or face, which receive their nerves di- 
rectly from the brain. But if, as generally happens, some point of the 
spine is from natural or accidental causes most irritable ; then as I have 
before suggested, the neuralgic irritation and inflammation will be de- 
veloped in that part of the system, which the irritated portion of the 
spine supplies with nerves, and for the reason, as I have before suggested, 
that the primary neuralgic irritation produces an irritation, congestion 
and rheumatic inflammation of the part or parts so supplied. 

In cases in which rheumatism passes from one point to another, rapidly, 
I am satisfied from careful observation, that it is in consequence of a 
change of the point of local irritation, in the cerebro-spinal system. That 
when it passes from the brain or heart to an extremity, it is from in- 
creased vital power, in consequence of which, the point of local conges- 
tion, or irritation in the brain or spine, is carried further from the nervous 
centre. But that when rheumatism passes from an extremity, to the 
heart or brain, it is from diminished vital energy, or power, in conse- 
quence of which, the point of irritation or congestion in the cerebro- 
spinal system, approaches the nervous centre. 

Such, I believe, are the causes direct and remote of rheumatic inflam- 
mation, and also the principles involved in its development. 

And I will only add, that my view of the increased proportion of 
fibrin in the blood ; and of uric acid, when it is in excess, is this ; that 
both are the effects, and not the cause of the disease. The increased 
proportion of fibrin, accumulating in the blood, I believe may be accounted 
for from a partial suspension of nutrition, and perhaps slight wasting in 
the muscular structures, during their diseased state, in consequence of 
which, the fibrin supplied by the food to nourish them, is retained, and 
accumulates in the blood in a greater or less degree, according to the 
extent and duration of the disease of the muscular structures. 

The presence of uric acid, when it exists in excess in the blood, if such 
be a fact, I think may be accounted for from the derangement of the 
perspiratory and secretory organs generally ; but I doubt, if an excess 
of uric acid, will very generally be found to exist in this disease. It is 
possible, also, that the derangement which I believe invariably exists in 
the cerebro-spinal system in this disease, may so far affect the ganglionic 
system of nerves, as to account in part, for the excess of fibrin in the 
blood, and also for the excess of uric acid, if such be a fact. 

Diagnosis. — Formerly rheumatism and gout were considered as the 
same affection ; but there are sufficient marks of distinction to entitle 
them to a separate consideration. The principal distinguishing features 
between the two affections are, the periodical recurrence of gout, after it 
has once invaded the system ; whereas rheumatism does not possess this 
14 



210 GENERAL INFLAMMATORY DISEASES. 

tendency so markedly, patients frequently passing without a second at- 
tack. Rheumatism is not so generally produced like gout, by indulgence 
in the free use of vinous drinks, and high seasoned, and stimulating ar- 
ticles of food. It is also less hereditary ; gout being often transmitted 
from parent to offspring, while such is rarely the case with rheumatism. 
Rheumatism too, is apt to occur in persons of debilitated relaxed condi- 
tions, while the reverse generally obtains with gout. 

Prognosis. — Although rheumatism is an exceedingly painful affection, 
it is not generally dangerous, so long as the inflammation is confined to 
external parts. But when it extends, or is translated to internal struc- 
tures, or organs ; as the heart, meninges of the brain, stomach, or lungs : 
the most serious consequences may be apprehended. Such cases may, 
however, from careful and judicious treatment, sometimes recover. 

Treatment. — If my view of the nature of rheumatism is correct, 
we have as the deviation from the standard of health, together with a 
too high or too low electrical state, generally retained perspirable matter, 
with perhaps the paludal poison, and various other morbid agents. 
There is also an irritation or congestion of some point of the brain or 
spinal cord, of either an active or passive character, and more or less 
functional derangement of the different organs, and especially of the 
secretory, and the local inflammation. 

The indications then are very plain ; to counteract any local irritation 
or congestion of either an active or passive character there may be in 
the cerebro-spinal system, to remove from the alimentary canal any 
bilious or irritating matters, to call the cutaneous exhalents into action, 
to restore the secretion and functions of the glandular system, and to 
subdue the local rheumatic inflammation. 

Cups should at once be applied over that part of the spine which sup- 
plies nerves to the inflamed part, for the purpose of removing any irri- 
tation or undue pressure that may exist, wet or dry according as the 
patient is in a sthenic or asthenic state. If the inflammation is in the 
meninges of the brain, or in the scalp, or about the face, the cups should 
be applied to the back of the neck, and if the patient be in a sthenic 
state, from two to four ounces of blood should be taken. If the rheu- 
matic inflammation is in the arms or upper extremities, the cups should 
be applied on each side of the spine, between the shoulders, over the seat 
of the bronchial plexis of nerves. If the disease be in the lower extremi- 
ties, the cups should be applied to the lumbar and sacral regions, in order 
to relieve the irritation of that portion of the spine. 

Having thus applied the cups on each side of the spine at the point 
supplying the inflamed parts with nerves, and taking from two to six 
ounces of blood, according to the general strength of the patient, and 
the degree of febrile reaction, a cathartic should be administered to clear 
the alimentary canal. Two or three blue pills, or ten grains of calomel 
should be administered, and followed by a full dose of the sulphate of mag- 
nesia, and a free evacuation of the bowels secured. If from any cause, 
a mercurial be contra-indicated, from half a drachm, to a drachm of the 
fluid extract of mandrake, or one or two grains of podophyllin may be 
given instead, and followed by castor oil, or half an ounce of the sulphate 
of magnesia if necessary. 



ACUTE RHEUMATISM. 211 

To promote perspiration, act gently upon the kidneys and bowels, and 
to reduce the general febrile excitement, the nitrate of potash, in from 
twenty to thirty grain doses, every four or six hours, dissolved in half a 
pint of warm crust coffee or gruel, is clearly indicated ; the gruel or crust 
coffee serving as drink and nourishment. If there is much nervous irri- 
(ability and the stomach is in a tolerable state, ten drops of the fluid ex- 
tract of colchieum, or twenty or thirty drops of the wine may be given 
with each dose of the nitrate. The nitrate, with or without the colchi- 
cum should be continued during the active stage of the general fever, and 
the local rheumatic inflammation. 

As an application to the inflamed part, from two to four drachms of 
the muriate of ammonia may be dissolved in half a pint of vinegar and 
water and applied cool or warm as is most agreeable to the patient, two 
or three times per day. Alter the general fever and the severity of the 
local inflammation is subdued, there generally remains more or less 
tenderness, thickening, and lameness of the parts involved. To remove 
this and to restore the action of the lymphatic and glandular system, the 
iodide of potassium, in ten grain doses, every six hours, should be given 
and the nitrate of potash discontinued. The iodide of potassium should 
be continued in this way till the soreness, lameness, and thickening of the 
parts are removed, when the dose should be diminished to five grains 
three times per day, and thus continued for one or two weeks to remove 
the effects of the disease. 

In bilious rheumatism, I have generally given about two grains of 
quinine and four or five of Dover's powder every six hours, at first, alter- 
nating with the nitrate for the purpose of arresting the fever, of which 
the rheumatism appears to be a complication in such cases; the Dover's 
acting as an anodyne and diaphoretic. In some cases, attended to early, 
I have succeeded with the cups, a cathartic, and warm sage tea; but if 
the local rheumatic inflammation has become established the other treat- 
ment is rendered necessary. If the rheumatic inflammation pass sud- 
denly to the heart, lungs, or brain, it is generally in consequence of 
great prostration, and it is usually followed by a decided sinking ten- 
dency. In such cases, the sulphate of quinine and Dover's powder, in 
five grain doses each, should be given every six hours, alternating with 
the iodide of potassium, and blisters applied over the inflamed part. 

Such, I believe, are the principles which should guide us in the treat- 
ment of acute rheumatism; and having pursued such a course of treat- 
ment for several years, I have no hesitation in recommending it; to be 
modified, of course, to meet the indications which arise in each particular 
case. If the indications be thus early met, I am satisfied that few cases 
need continue for many days, and none go on to a protracted chronic 
state; at least, such has been the result of my observation. But if acute 
rheumatism be neglected or mal-treated in its early stages, it may pass 
into a chronic form and continue for many weeks. 

The gruel or crust coffee in which the nitrate of potash is given, 
affords sufficient nourishment while that is continued, but when that is 
no longer indicated, toast and other light food should be allowed at 
regular meal hours. 



212 GENERAL INFLAMMATORY DISEASES. 

SECTION II.— CHRONIC RHEUMATISM. 

By chronic rheumatism, I mean that peculiar chronic rheumatic in- 
flammation, affecting most frequently the joints, but which may occur in 
the fibrous, synovial, muscular, or in fact any tissue or organ of the 
body. Chronic rheumatism is very generally the result of neglected or 
mal-treated acute rheumatism, but it may arise in the system in the 
same manner, and from the same causes as acute rheumatism, no active 
inflammatory fever being developed, and the local rheumatic inflamma- 
tion being of a passive or chronic character. 

When chronic rheumatism is not a consequence of the acute disease, it 
arises from the same causes, and is developed in the same manner as the 
acute variety, only there is frequently a distinct tenderness of the spine, 
at the point where the nerves come off which supply the affected part. 
The neuralgic irritation which is set up is generally not so violent, and 
does not so readily develop the rheumatic inflammation ; and when the 
inflammation does arise, it is of a slow chronic or passive character. 

Symptoms. — At first there may be a dull, heavy feeling in the head, 
or along the spine, with slight drowsiness, or lassitude, and a general 
feeling of coldness or chilliness. Sooner or later slight febrile reaction 
may take place, with slight increase in the frequency of the pulse ; more 
or less thirst; a dry skin, and perhaps scanty high-colored urine. Soon 
the dull, heavy feeling in the head, or along the spine, appears to be 
concentrated at some particular point in the brain or along the spine, 
which point, if it be in the spine, becomes often more or less tender, and 
immediately the darting neuralgic pains are felt in the limb or part 
which this irritated point supplies with nerves. 

After this neuralgic pain has continued for a longer or shorter period, 
the patient being more or less restless or uneasy, especially at night, a 
slight swelling, tenderness, and perhaps redness appear in the joints, 
limbs, or parts in which the neuralgic irritation had been set up, and 
this, if neglected, may continue for days, weeks, months, or even years, 
being increased or lessened according to the exposure or imprudence of 
the patient, and also modified more or less by the dampness or electrical 
state of the atmosphere. It may continue confined to some particular 
part for a long time, with only a slight swelling, and lameness of the 
part, or it sometimes assumes an erratic character, passing from one 
part of the system to another, and attended with considerable pain, but 
no great tenderness or swelling. 

In cases in which it remains stationary for a long time, there is gene- 
rally a decided irritation, and often tenderness at the point of the spine 
supplying nerves to the affected limb or part; but in the erratic cases, 
I have generally detected only a transient irritation, with slight pain, 
but little or no tenderness of the spine, to retain the local inflammation 
in one part, so that it shifts, as the point of greatest irritability in the 
cerebrospinal system passes from one point to another. 

In erratic cases, when the general strength is declining, I have gene- 
rally noticed the local disease to pass to more important or vital parts, 
indicating that the point of irritation in the cerebro-spinal system is 
approaching the nervous centre. But if the general strength is im- 



CHRONIC RHEUMATISM. 218 

proving, and the cause being removed, I have generally noticed that the 
rheumatic inflammation passes from important or vital parts towards the 
extremities, or less vital parts, thus indicating that the point of irrita- 
tion in the cerebro-spinal system is passing from the brain or nervous 
centre. 

Thus we have the symptoms, and as I believe the principles involved 
in chronic rheumatism, which are very similar to those of the acute, 
only the disease is less violent, and of a more passive or chronic cha- 
racter, depending upon the peculiarly weak or debilitated condition of 
the patient, and perhaps a less concentrated exciting cause. 

Diagnosis. — The only diseases with which chronic rheumatism is liable 
to be confounded, is neuralgia and gout, from both of which it may 
generally be distinguished by attending carefully to the following diag- 
nostic symptoms. I regard the early pain, which precedes the inflam- 
mation, as purely neuralgic. But when the rheumatic inflammation 
takes place, the pain becomes more continuous, is less lancinating, and 
more dull, and there is generally tenderness, swelling, and sometimes 
redness, which rarely occurs in neuralgia, unaccompanied with rheu- 
matic inflammation. 

Chronic rheumatism may be distinguished from gout, by the fact of its 
being less hereditary, by its occurring in weak, relaxed, and debilitated 
constitutions, while gout generally occurs in persons of luxurious and 
idle habits. Besides, rheumatism is less periodical than gout, less liable 
to return, is attended with less derangement of the digestive organs, and 
while the blood in rheumatism contains only a trace of uric acid, it 
exists in an abnormal proportion in gout. 

Causes. — A debilitated, relaxed and depraved condition of the system, 
together with an irritable condition of the cerebro-spinal system, consti- 
tutes, I am confident, a predisposition to chronic rheumatism ; while 
among the exciting causes, retained perspirable matter, a low electrical 
state, and various irritations of the brain and spine, operate as exciting 
causes. 

In persons strongly predisposed to chronic rheumatism, by a depraved, 
relaxed and debilitated condition of the system, the various functions of 
the body are more or less imperfectly performed, and especially the per- 
spiratory function. In such persons the skin is stimulated to carry on 
its functions while the weather is fine and the air dry, and well charged 
with electricity, but as the weather becomes changeable, the air damp, 
and consequently in a low electrical state, the system parts with so much 
of its electricity that the different functions of the body become more or 
less impaired, or interrupted, and especially that of the skin. As a con- 
sequence of this, the perspirable matter is retained, and passing with the 
blood to the brain and spinal cord, produces a debilitating or irritating 
effect, which effect falls, or is concentrated upon the most irritable point 
or points of the brain and spinal cord, and hence a neuralgic irritation, 
and finally rheumatic inflammation is developed, of a slow or chronic 
character, and attended with little if any general febrile excitement, in 
some cases at least. 

Patliology. — After what I have said of acute and chronic rheumatism, 
but little need be added to explain my views of the pathology of this 



214 GENERAL INFLAMxMATORY DISEASES. 

disease in all its forms. I am satisfied that retained perspirable matter, 
or something that will produce an equivalent effect, passes with the blood 
to the brain and spinal cord, producing a poisonous effect, debilitating 
perhaps in all cases, at first, but in sthenic constitutions soon producing 
irritation, followed by more or less active congestion of that portion of 
the brain or spinal cord which, from hereditary or accidental causes, is 
most predisposed to take on irritation or congestion. 

In consequence of this congestion or irritation of some point of the 
cerebro-spinal system, a neuralgic irritation is set up in the limb or part 
which the irritated or congested portion of the brain or spine supplies 
with nerves. This neuralgic irritation irritates or debilitates the capil- 
laries of the fibrous, muscular, or other tissues to which the irritated 
nerves are distributed, and as a consequence we have a local rheumatic 
inflammation developed, of a greater or less extent, according to the de- 
gree and extent of the neuralgic irritation, and the accidental predispo- 
sition to the disease. There is also an irritation transmitted from the 
cerebro-spinal to the ganglionic system, in consequence of which we have 
an irritable condition of the heart and arteries, which in sthenic consti- 
tutions is attended with increased power of action, and so a general 
febrile excitement is set up, either before or after the establishment of 
the local rheumatic inflammation. 

In debilitated, relaxed, and depraved constitutions we have in the same 
manner set up a passive irritation of the brain or spine, and also an irri- 
tation transmitted thence not only to the capillaries of the part where 
the local disease is to be developed, but also to the heart and arteries ; 
but in both, as the system is in an asthenic state, the irritations are 
attended with diminished power of action in the capillaries, as well as in 
the heart and arteries ; hence we have either a passive or chronic inflam- 
mation as the result. 

The agency of electricity in the production of this disease, I have 
already explained, but it should be remembered that electricity should 
only be supposed to act as a cause of rheumatism in constitutions which 
are either above or below a medium, or in a sthenic or asthenic state ; 
in the sthenic producing an influence in developing acute inflammatory 
rheumatism, while in the asthenic it favors the development of passive 
or chronic rheumatism. 

The presence of an undue proportion of fibrin in the blood in rheuma- 
tism, I have accounted for in the preceding section, as generally an effect 
and not a cause of the disease ; supposing that it may arise from a par- 
tial suspension of nutrition in the muscular structures, and perhaps also 
from a slight wasting of the muscular structures involved, thus causing 
to be retained or accumulated in the blood an abnormal proportion of 
fibrin. 

Prognosis. — The prognosis of chronic rheumatism is favorable so far 
as a fatal termination is concerned, unless the heart, or some other vital 
organ or part becomes involved ; in which case the disease is always at- 
tended with more or less danger. 

The prognosis in chronic rheumatism, so far as an ultimate and perma- 
nent recovery is concerned, depends upon the time the disease has con- 
tinued, and also upon the hereditary and accidental predisposition to the 
disease. 



CHRONIC RHEUMATISM. 215 

Treatment. — The indications in the treatment of chronic rheumatism 
are to relieve any local irritation there may be in the brain, or spinal 
cord ; to promote perspiration ; to restore the healthy action of the glan- 
dular system, and to correct any deranged, or depraved condition of the 
system that may exist. If there is much spinal tenderness ; dry cupping, 
blistering, or tartar emetic pustulation should be resorted to at once, on 
each side of the spine, at the tender point. 

Having removed the local irritation of the brain or spine, if it exists ; 
if the inflammation is sub-acute, half an ounce of the sulphate of mag- 
nesia should be administered at once, and then ten drops of the fluid 
extract, or thirty or forty drops of the wine of colchicum should be ad- 
ministered every four or six hours, till the general febrile excitement is 
checked, and an impression produced on the local rheumatic inflamma- 
tion. As soon as a decided impression is produced, the wine of colchicum 
should be given, in twenty or thirty drop doses, or the fluid extract, in 
from eight to ten drop doses, every six hours, and alternating with this, 
the iodide of potassium, in ten grain doses should be given every six 
hours, till the local disease is subdued ; after which, the iodide should be 
continued in five grain doses, three times per day, for a few days, to remove 
the effects of the disease. 

In cases of chronic rheumatism, which depend mainly on the influence 
of cold, a torpid condition of the skin, and a general debilitated and re- 
laxed condition of the system, the gum guiac, in twenty or thirty grain 
doses, three times per day, is a valuable remedy. The pulverized gum 
may be mixed with gum arabic and sugar, and then by the addition of 
water, a convenient mixture may be formed. If such cases prove ob- 
stinate, twenty-five drops of the fluid extract of the blue cohosh* may 
be given, alternating with the guiac, four times per day, and continued 
till the disease, and its effects are removed as far as may be. 

In all those cases of chronic rheumatism, in which the abuse of 
mercury is a cause, or in which there is a syphilitic taint, with a marked 
derangement of the skin and glandular system ; the iodide of potassium 
should be given in ten grain doses, three times per day, with full doses 
of the compound decoction of sarsaparilla, and continued till the disease 
is removed. This treatment in some cases, may require to be continued 
for several weeks, or even months ; but if persevered in for a reasonable 
time, it will generally effect a cure, at least such has been the result of 
my observation. 

By a strict observance of these principles, varying of course to meet 
the indications which arise in each particular case, carefully fulfilling the 
indications by the proper remedies, the most obstinate and protracted 
cases of chronic rheumatism may be greatly relieved, and very many 
permanently cured. 

Rheumatic patients should be directed to keep the skin clean, and the 
feet dry ; to wear flannel next the skin, during the cold, damp, and varia- 
ble weather, and to observe with the greatest care, those rules of propriety 
in all things, most conducive to health, and its preservation, always pre- 
serving an even and cheerful temper of mind. 

* Leoutice Thalictroides. 



216 GENERAL INFLAMMATORY DISEASES. 



SECTION III.— GOUT. 



By gout I mean that peculiar general inflammatory disease occurring 
in either an acute or chronic form, and affecting most frequently the 
smaller joints, but liable, like rheumatism, to be translated to internal 
and vital parts. In acute cases of gout the disease is attended with 
more or less febrile excitement ; but in cases which become chronic, or 
which are chronic from the commencement, there is little or no general 
fever attending the disease. 

Symptoms. — An attack of acute gout is generally preceded by more 
or less derangement of the digestive organs ; the tongue is foul and 
redder than natural; there is loss of appetite, sour stomach, and perhaps 
vomiting; distress in the stomach and drowsiness after eating, and 
generally depression of spirits and restlessness during the night. The 
feet are cold and perhaps soon distressingly hot ; a pricking, darting or 
numb sensation is felt in the legs and feet, especially in the foot that is 
about to be attacked ; and some hours previous to the paroxysm there is 
slight shivering alternating with flushes of heat. 

After more or less of these symptoms have continued for a time, the 
paroxysm develops itself generally between one and three o'clock in the 
morning. The patient awakes with a violent throbbing pain, generally 
in the ball of one of the great toes, but sometimes at the heel, instep or 
ankle. This pain goes on increasing accompanied with a sensation of 
burning heat, weight and stiffness of the part, and severe shooting pains 
in the limb. The severe pain is usually attended at first with shivering, 
but soon the joint begins to swell, and more or less fever is developed 
with great restlessness. As the local inflammation is developed, the 
affected joint becomes swelled, hot, red and tender ; so that the weight 
of the bedclothes can hardly be borne. The superficial veins about the 
affected part and for some distance up the limb become turgid, and all 
the symptoms of the local disease continue from six to twenty-four hours ; 
after which the violence of the pain subsides, but the swelling rather 
increases and becomes more or less edematous. 

Nearly or quite simultaneously with the local affection, the febrile 
symptoms are developed, the chilliness being followed by an increased 
heat of the skin, disgust of food, a furred tongue and scanty high-colored 
urine. The fever continues with the local affection, unabated for a 
period varying, as I have stated, from six to twenty-four hours. Gene- 
rally I think the violence of the local pain, as well as the general fever, 
begin to subside about midnight, following the morning of the attack, so 
that by two or three o'clock in the morning the patient may fall asleep, 
after twenty-four hours of severe suffering. 

The following evening the pain and fever are renewed and continue 
through the night to abate again in the morning ; and thus the disease 
passes on, with remissions during the day and exacerbations at night, each 
paroxysm being less severe than the preceding one, till at last the attack 
terminates perhaps after having continued a week or ten days, especially 
in the first attacks of the disease. After the pain and fever have subsi- 
ded, or during their subsidence, there is often slight looseness of the 
bowels, a gentle perspiration and a copious discharge of urine. There is 



GOUT. 217 

slight itching in the part which has been inflamed, the skin falls off as 
the swelling subsides, and the patient finally recovered from the attack, 
feels in every respect much better than before the attack. 

The first attacks of gout as we have seen, seldom last but a few days, 
or affect more than one joint, but when the disease has gone on for some 
time, the inflammation when declining in one foot, suddenly attacks the 
other, and sometimes the fingers, wrists, knees ; and then the pain, shiver- 
ing, fevers, swelling and redness, and all the symptoms recommence. 
At the end of three or four days the pain is again relieved, but the 
attack does not end here, as a similar fit supervenes affecting the same 
or other joints, accompanied with the same series of symptoms, and con- 
tinuing perhaps for the same length of time. Hence to complete an 
attack of gout, three or four fits may occur, each taking from three to 
five days to run its course ; about fifteen days, perhaps, being the average 
duration of an attack, but it may continue much longer than that. 

After gout has affected a person for several years, the attacks are not 
only lengthened, but they occur more frequently. At first, the attacks 
may occur no oftener than once a year ; later, they may come on every 
six months, then every three months, and finally, as the paroxysms occur 
with much greater frequency, and are of much longer duration, the 
patient is scarcely over one attack, before another occurs, and so the 
patient is laboring under the disease, as it were, almost constantly, with 
only imperfect remissions. But as the disease progresses, and becomes 
more continuous, the attacks are less violent, there being generally less 
pain and redness, though the swelling may be quite as much or more. 
The joints do not now completely recover between the paroxysms as at 
first, but remain more or less stiff and incapable of motion. 

The grade of the inflammation is lower and the general fever less 
vigorous than in the early attacks of the disease, corresponding more or 
less with the diminished vigor of the system. At this stage of the disease, 
it is very liable to affect internal or vital parts, as the brain, heart, lungs, 
stomach, bowels, liver and kidneys, and when it does, the symptoms of 
inflammation and functional derangement of the internal part which be- 
comes affected, are developed with more or less intensity. If the stomach 
becomes involved, we have the ordinary symptoms of gastritis; if the 
bowels, there is often a diarrhoea or severe colic ; if the heart, there is 
precordial oppression, violent pains, dyspnoea, syncope, &c. ; if the lungs, 
difficult breathing, lividness of the face, a feeble pulse, &c. ; if the liver 
or kidneys, there is developed symptoms of inflammation or functional 
derangement of those glands, and finally, if the brain becomes involved, 
there is more or less stupor, and in some cases, palsy or apoplexy. 

As gout thus assumes a chronic character, it may appear at each 
paroxysm in some one of these internal vital organs, or it may appear 
externally, in some of the small joints, and be translated to the internal 
part in consequence of the debilitated condition of the system. In either 
case there is danger of organic visceral disease, which may lead to a 
fatal termination, such as of the brain, heart, lungs, liver or kidneys ; if 
these internal parts become often seriously affected. 

Chronic gout may be the result of the acute form of the disease, as we 
have seen, or it may assume a chronic form from the first invasion of the 



218 GENERAL INFLAMMATORY DISEASES. 

disease ; especially in persons of a feeble constitution, and of indolent 
intemperate habits. The disease may be regarded as chronic when with 
the moderate local affection there is produced little or no general fever. 
In chronic gout the paroxysms are frequent, but less severe than in the 
acute form of the disease. There is little pain except on motion ; but 
slight increase of heat ; and, instead of redness, more or less of a pur- 
plish hue. If there is swelling it is of an edematous character, unless it 
be from an increase of the synovial fluid of the joints, as is sometimes 
the case. 

The paroxysms occur very irregularly, sometimes coming on after an 
interval of a month, and at other times they may run into each other — a 
new attack appearing before the preceding has subsided. In some cases 
the disease remains fixed in particular joints, while in others it may pass 
from joint to joint, or it may be translated to internal or vital parts. 

In fixed cases of chronic gout the joints often become nearly or quite 
useless, in consequence of a thickening of the ligaments, with the addi- 
tion, in some cases, of a deposition of an earthy matter like chalk, either 
into the cavity of the joint itself or into the cellular tissue about the 
joint. The uric acid and urate of soda, of which the concretions chiefly 
consist, is probably first deposited in a semi-liquid state, and afterwards 
becomes dry by absorption of the fluid parts, leaving the chalk stones, 
varying in size from that of a mustard seed to a walnut, and sometimes 
much larger than that; producing, in some cases, swelling, ulceration, 
and even mortification of the surrounding tissues. 

The characteristics then of chronic gout, are very little or no fever, an 
edematous swelling of the inflamed parts of a purplish hue, the patient 
having a sallow complexion, with a more or less flaccid state of the flesh, 
and a general appearance of being worn down by protracted suffering 
and disease, and finally either a deposition of uric acid in or about the 
joints, or else a more or less copious discharge of it with the urine, espe- 
cially as a paroxysm is about terminating. 

Thus we have the general symptoms of acute and chronic gout, under 
which heads I have included all cases of gout in which there is either 
general fever and local inflammation, or inflammation without fever. 
There is however a gouty diathesis, in which various neuralgic affections 
are developed, with more or less functional derangement of the parts, in 
the treatment of which the gouty diathesis should always be taken into 
the account ; but I doubt if such neuralgic affections should be regarded 
as gout, any more than neuralgia should be confounded with rheumatism. 

Various conditions, too, have, from the resemblance of the symptoms 
developed to those of rheumatism and gout, been denominated rheumatic 
gout ; but I believe that the condition partakes, in every case, much more 
decidedly of either the one or the other disease, and that the morbid con- 
dition should therefore be regarded as either rheumatism or gout, unless 
per chance both diseases be found to exist in a patient at the same time, 
which very possibly may sometimes be the case. 

Anatomical Characters. — In acute gout the patient generally dies from 
an extension or translation of the disease to some internal or vital part, 
in which case the ordinary signs of inflammation of the affected part or 
parts are presented on post-mortem examination. In cases in which the 



GOUT. 219 

patient has suffered from chronic gout evidences of inflammation are 
exhibited in the synovial membrane of the affected joints, as well as in 
the interarticular cartilages. The bones, too, near the joints are found 
injected with blood, perhaps softened, and, in some cases, eroded, and 
the cartilages covering the articulating ends of the bones may be found 
more or less absorbed. The ligaments are found injected, and sometimes 
thickened ; and the muscles in the vicinity are either contracted or more 
or less wasted. And finally, layers of chalky matter are sometimes 
found, either without the joint in the cells of the areolar tissue, of the 
periosteum, ligaments, fascia, or muscles, or else within the synovial 
membrane, or between it and the adjoining cartilages. 

Diagnosis. — Gout is not likely to be confounded with any other disease, 
except rheumatism ; from which it may generally be distinguished by 
attention to the following differences : Gout is much more hereditary 
than rheumatism, and it very seldom attacks children, which is not so 
generally the case with rheumatism. Gout is found most frequently 
affecting the idle, luxurious, and wealthy ; while the reverse of this is 
true of rheumatism. 

Gout too is very prone to attack the small joints, is more paroxysmal, 
the fever is less continuous, the pain is more violent, the inflamed parts 
are of a brighter red, or else of a purplish hue, there is greater swelling 
and a more edematous tendency ; and finally there is desquamation follow- 
ing the subsidence of the inflammation, which is not the case in rheuma- 
tism. If all these peculiar differences are carefully observed, and the 
history of chronic cases taken into the account, I think little or no 
difficulty need be experienced in arriving at a correct diagnosis in 
genuine cases of gout. 

Causes. — The predisposition to gout is no doubt often hereditary, being 
transmitted through several succeeding generations, even though the 
disease may not be developed in each ; in many cases, thus, " the 
iniquities of the fathers are visited upon the children to the third and 
fourth generation." It is probable also that the gouty diathesis may be 
generated in those not hereditarially predisposed, by the use of an undue 
proportion of animal food, indulgence in alcoholic liquors, gluttony and 
an indolent habit of life, together with various other imprudences. 
When the gouty diathesis exists, whether it be hereditary or acquired 
by imprudent habits, very slight causes, such as a full meal, the use of 
alcoholic liquors in any form, exposure to cold, venereal excesses, anger, 
indigestible food, acids, injuries ; and various other like causes may 
develop the disease. 

Gout is most liable to make its first appearance between the twentieth 
and fortieth years of age, and it most frequently occurs about the time 
of the vernal and autumnal equinoxes. It is probable also that gout is 
more liable to occur in damp variable climates, as it is more common in 
temperate latitudes where the weather is variable, than at the extreme 
north or in the tropical regions. 

Pathology. — In relation to the nature or pathology of gout, there may 
be grounds for doubt. But when we take into account the facts con- 
nected with the disease, so far as we are capable of ascertaining them, it 
appears to me that we have at least a clue to what may be regarded as 



220 GENERAL INFLAMMATORY DISEASES. 

the probable pathology of this peculiar disease. "When we remember 
that the gouty diathesis may be produced by the use of alcoholic drinks, 
or by an undue proportion of animal food, the latter of which favors the 
formation of uric acid in the system, and both if used in excess, not only 
impair digestion, but also render the nervous system more or less irritable, 
involving of course the brain and spinal cord ; it appears to me that we 
have at least a starting point from which we may proceed to a probable 
pathology. 

If now we have this peculiar irritable condition of the nervous system, 
whether it be hereditary or produced by imprudence in eating and 
drinking, as I have already suggested, it appears to me that the presence 
of uric acid in the blood, if the quantity be considerable, may, by passing 
with the blood through the system, not only affect the brain and spinal 
cord to produce the violent neuralgic or darting pains, but also directly 
to assist in developing the gouty inflammation. The uric acid, as it 
accumulates in the system, may produce a debilitating effect upon the 
brain and spinal cord, and lead on to the chills which occur, and also 
to the violent, darting, neuralgic pains which immediately precede the 
local inflammation. 

It is possible that the local inflammation may be the result of the neu- 
ralgic pain, set up in the part, affecting the capillaries about the joints, or 
parts which become the seat of the disease. But I suspect, that in ad- 
dition to the peculiar diathesis, and the neuralgia which is set up, as I 
have suggested, that the development of the inflammation, is aided at 
least, by the uric acid passing through the capillaries of the tissues of the 
small joints, or parts which become inflamed. 

In acute gout then, we have the irritable condition of the nervous sys- 
tem, the presence of uric acid in the blood, irritating, or debilitating the 
cerebro-spinal system, which leads on to a chill, during which, there is 
more or less congestion of the brain and spinal cord ; which congestion 
produces an irritation of the spinal cord, or brain, in addition to that 
already set up. Now as a consequence of all this, the ganglionic system 
becomes involved, producing an increased action of the heart and arteries, 
developing general fever. At the same time, the neuralgic pain in the 
small joints, or parts to become affected, develops, by the help of the 
irritant in the blood, the local inflammation. 

Now in acute cases, occurring in plethoric overfed constitutions, the 
irritation set up in the capillaries of the joints, as well as the irritation 
set up in the heart and arteries, are attended with increased power of 
action, so that there is developed an active inflammation, as well as a 
vigorous general fever. The peculiar appearance of the inflamed part, 
as well as the peculiarity of the fever, may be owing to the peculiar irri- 
table condition of the system, constituting, as I believe, the gouty 
diathesis ; and also in part to the excess of uric acid, or urate of soda in 
the blood. 

The disease remits during the day, and has exacerbations during the 
night, perhaps in part, owing to the dampness of the night air, and its 
consequent effect upon the cutaneous exhalation, and perhaps in part 
also to changes in the electrical state of the air. After the paroxysm 
has continued for a few days, the kidneys, either by the natural effort of 



GOUT. 221 

the system, or by the effects of remedies, drain off the excess of uric 
acid in the blood, and so the paroxysm, with all its general and local 
symptoms subsides, and leaves the patient feeling in every respect better 
than before the attack, when the morbid product was accumulating in 
the blood. 

As the uric acid accumulates in the blood, time after time, the paroxysms 
are produced in the same manner ; only the irritation of the brain and 
spinal cord becomes more permanent. The general irritability of the 
system is increased, but vital power is diminished ; and as a consequence 
of all this, the paroxysms occur more frequently. But as both the 
capillary, and general circulatory systems become irritated, they have 
gradually a diminished power of action ; and hence the passive character 
of the general fever, and local inilammation, as the disease becomes 
chronic. And finally as the brain and spinal cord become constantly 
irritable, the neuralgic pains become almost constant. The heart and 
arteries are also constantly irritated ; but as they have diminished power 
of action, there is finally no general fever developed. And as the local 
irritation of the capillary vessels is also attended with diminished power 
of action, the local inflammation assumes a slow passive character ; and 
thus we have accounted for the phenomena of both acute and chronic 
gout, in all its forms. 

In the same manner we may account for chronic cases, that never had 
assumed the acute form. 

But in those cases of neuralgia which occur from a gouty diathesis ; 
that is from an irritable condition of the cerebro-spinal system, in which 
various neuralgic symptoms are developed, with more or less functional 
derangement of the different organs, without any general fever, or local 
inflammation, I prefer to consider the morbid condition as neuralgia, de- 
pending upon the gouty diathesis, as a cause. I shall therefore treat of 
those neuralgic affections, which have been called nervous gout, under 
the head of neuralgia, where it appears to me, they more properly belong. 

Now, if my view of the pathology of gout be correct, we have a ready 
solution of the reason why gout so often passes suddenly from the small 
joints of an extremity, to some internal or vital part, and the reverse. 

For, as we have seen in rheumatism, it is only necessary that the 
general powers of the system decline, for the point of greatest irritabili- 
ty in the cerebro-spinal system to approach the nervous centre ; and 
hence the point of the neuralgic irritation, and inflammation is changed 
to the internal or more vital part. And on the other hand, if gout at- 
tack an internal or vital part, in a feeble patient, if the vigor of the 
system be improved, the point of greatest irritation in the cerebro-spinal 
system may recede from the nervous centre, and as a consequence, the 
neuralgia pass from the vital part to an extremity, and with it, the local 
inflammation. 

This view of the pathology of gout, it appears to me, receives con- 
firmation in the fact that the gouty diathesis often produces various 
neuralgic affections, and functional derangement of the different organs 
of the body, which appear to point directly to the brain and spinal cord 
as the seat of the difficulty. Thus I have explained what appears to me 
to be the nature or pathology of gout, and while it must be confessed 



222 GENERAL INFLAMMATORY DISEASES. 

that the subject is involved in what may be regarded as a reasonable 
doubt ; I know of no symptom developed in this disease, which may not 
be rationally accounted for, allowing this to be the true explanation of 
its pathology. 

Prognosis. — The prognosis in gout so far as a fatal termination is con- 
cerned, is not very unfavorable, unless it passes by extension or transla- 
tion to some internal or vital part, in which case the danger is always con- 
siderable. In protracted cases too, in which digestion becomes seriously 
impaired, the nervous system excessively irritable, and the powers of 
life very much reduced, with general functional derangement of the 
different organs of the body, the patient is liable to be cut down by 
some acute disease, or else to be taken off by some form of dropsical 
affection. 

If the inflammation tends to pass from the internal vital parts towards 
the extremities, it indicates increased vigor of the system, and the prog- 
nosis becomes more favorable. But if the gouty inflammation tends to 
pass from the extremities to the internal vital parts, it indicates dimin- 
ished vital power, and the prognosis is always rendered more unfavor- 
able. 

Treatment. — The deviation from the standard of health in gout, con- 
sists evidently in a peculiar irritable condition of the system, constituting 
the gouty diathesis, in a deranged condition of the digestive organs, 
caused generally by abuse in eating too much animal food, and drinking 
too much alcoholic liquors, and in an accumulation of an undue amount 
of uric acid in the blood, together with the local inflammation, and the 
general febrile excitement. The indications then are very plain, both 
during a paroxysm, and also between the attacks, or in the intervals. 

The habit of using alcoholic drinks in any form should be avoided by 
persons of a gouty diathesis, and should not be allowed except in cases 
in which the habit has been of long duration, and even in such cases, it 
may generally be broken off by degrees, and the condition of the patient 
very materially improved. In persons that have not the gouty diathesis, 
the use of alcoholic liquors should be avoided, lest the diathesis be formed, 
as well as various other morbid conditions of the system produced. 

As the use of an undue proportion of animal food, favors the forma- 
tion of uric acid in the system, gouty patients should always use due 
caution, that no more than a reasonable amount of animal food be taken ; 
and that food always be taken at regular meal hours. If, however, the 
gouty diathesis be hereditary, or acquired by intemperance in eating, 
drinking, &c, and with this predisposition, a too free use of animal food, 
with indolence and other causes which operate to produce the disease, be 
indulged in, uric acid accumulates in the blood, and a paroxysm of gout 
is the result. 

In such a case, as the digestive functions are always, impaired, a cath- 
artic of calomel or blue pill, followed by half an ounce of the sulphate of 
magnesia, is generally indicated, or if from any cause a mercurial be 
contra-indicated, from half a drachm, to a drachm of the fluid extract of 
mandrake, or one or two grains of podophyllin may be given instead, 
and followed by the sulphate of magnesia if necessary. 

Having thus cleared the alimentary canal, and gently stimulated the 



gout. 223 

liver and glandular system, it is desirable to bring the skin and kidneys 
into a state of renewed activity, and also to favor the secretion by 'the 
kidneys, of the excess of uric acid in the blood. To act thus upon the 
skin and kidneys, no remedy appears better adapted in acute cases, than 
the colchicum. From ten to twelve drops of the fluid extract, or from 
thirty to forty drops of the wine may be given every four or six hours, 
and continued till the paroxysm has abated, when the dose may be 
diminished one-third, and continued till the fever and local inflammation 
have entirely subsided. 

If an anodyne becomes necessary to secure rest, fifteen drops of the 
fluid extract of hyoscyamus may be given at evening, and repeated if 
necessary once during the night. Or if the bowels are in a relaxed 
state, Dover's powder may be given instead. If there is much acidity 
of the stomach, half an ounce of the bicarbonate of potash may be dis- 
solved in a pint of water, and an ounce of the solution given three times 
a day, at meal hours, and continued till the acidity is corrected, or, if 
the acidity be slight, half an ounce of the solution may be given instead. 
If the colchicum fails to keep the bowels sufficiently loose, small doses of 
magnesia, or of the sulphate of magnesia may be given occasionally 
during the continuance of the paroxysm, that one or two movements may 
be secured every twenty-four hours. 

While the fever continues, the diet should consist mainly of light farin- 
aceous substances, as sago, arrow-root, &c, with a little chicken broth 
and toasted bread, and as a drink, toast water may be allowed. 

The patient should take exercise as soon as the paroxysm is over, and 
he will generally find some relief from friction of the part with the hand, 
or an application of the tincture of camphor if swelling remains after the 
inflammation has entirely subsided. 

In acute gout, if the disease occur in or extend to the stomach, heart, 
brain, or some other internal or vital part, prompt measures should be 
taken to arrest the inflammation. If it be not a translation of the dis- 
ease, the result of a sinking tendency, general bleeding may be indicated, 
and should be resorted to, together with cups, blisters, and other mea- 
sures ordinarily indicated in inflammation of the part. 

In chronic gout the patient should be restricted to a regulated diet; 
should avoid the use of all kinds of alcoholic liquors ; should wear warm 
clothing : take sufficient exercise ; preserve a mild and even temper of mind ; 
and, in short, should conform most rigidly in every respect to the laws of 
health. If there is acidity of the stomach, it may be corrected by a 
weak solution of the bicarbonate of potash, taken after each meal for a 
few days; or if that be unpleasant, the prepared chalk maj be taken 
instead. If the bowels are confined, a pill of equal parts of aloes and 
rhubarb should be taken at evening, and continued till the habit is cor- 
rected. 

If, however, in spite of every precaution a paroxysm occurs, ten drops 
of the fluid extract, or thirty drops of the wine of colchicum should be 
given three times a day, after each meal, and continued till the par- 
oxysm is over, and then diminished one-third and continued for a week 
or two. If from any cause the colchicum disagrees, twenty or thirty 
grains of gum guiac may be given instead, made into an emulsion with 



224 DISEASES OF THE NERVOUS SYSTEM. 

sugar, gum arabic and water taken after each meal, and continued, if 
necessary, for several weeks. In those cases of chronic gout in which 
the joints become permanently swelled, stiff and lame, or almost useless, 
five grains of the iodide of potassium may be given three times a day 
before each meal and continued for several weeks or even months, often 
with the most happy effects. It should be given well diluted in water, 
or what in many cases will do better, with the compound decoction of 
sarsaparilla. 

In cases of chronic gout, if from great debility the disease be suddenly 
translated to some internal vital part, warm stimulating applications 
should be made to the original seat of the disease, and cups, wet or dry, 
applied over the inflamed part, and the system sustained by two or 
three grains each of quinine and camphor every six hours. Blisters also 
over the inflamed part may be of essential service in such cases. 

In all protracted cases of chronic gout, in which, with the indigestion, 
great poverty of the blood occurs, with a dropsical tendency, a reason- 
able amount of animal food maybe allowed, and every possible care taken 
to improve the digestion, and to sustain the sinking powers of the 
system. And if dropsy occur, it should be treated on general principles, 
taking into account, of course, the general condition of the patient. 

In all cases of neuralgia, occurring in patients of a gouty diathesis, 
the treatment must be as in neuralgia from other causes, taking into 
account, of course, the gouty diathesis. 



CHAPTER VII. 

DISEASES OF THE NERVOUS SYSTEM, 



SECTION I.— CEPHALALGIA— {Headache.) 

By the nervous system I mean the brain, spinal cord, cerebro-spinal 
nerves, and the sympathetic or ganglionic system. The cerebro-spinal 
system is composed, it will be remembered, of white fibrous tubular 
matter, and a gray vesicular substance. The gray vesicular substance 
occupies the surface of the cerebral mass, but the central portion of the 
spinal cord, while the cerebro-spinal nerves are composed entirely of 
white fibrous tubular material. 

Nervous matter consists of albumen, phosphorus, and various fatty 
substances. The sympathetic nerves, extending from the brain along 
each side of the spine, are of a grayish color and consist of numerous 
ganglia, connected by branches, and receiving branches from the cerebro- 
spinal nerves. 

The brain is supplied with blood by the carotid and vertebral arteries, 
is surrounded by a fibrous, serous, and vascular membrane, and, together 



CEPHALALGIA. 225 

with the nervous system generally, is the medium through which mind 
controls the body, and by which all the functions of the body, both 
voluntary and involuntary are sustained. The cerebral hemispheres 
appear to be the more immediate seat of the mind, and especially their 
external, gray, or vesicular portion appears to be devoted to intellection ; 
while the function of the spinal cord appears to be physical, and the 
nerves " mere conductors of sensations, volitions, and impulses direct and 
reflex, between the nervous centres and their extremities." 

It is probable that the nervous centres generate a nervous power or 
influence, which being sent forth through the nerves exercises a control- 
ling influence upon the various functions of the different organs of the 
body; the sympathetic system influencing especially the circulation, 
digestion, absorption, nutrition, and secretion ; while the cerebro-spinal 
nerves influence more especially the voluntary functions. The brain, 
then, the great centre of the nervous system, receiving near one-fifth of 
all the blood which passes through the heart, invested with its mem- 
branes, of a fibrous, serous, and vascular character, is liable to a great 
variety of inflammatory, organic, and functional derangements, many of 
which are attended with cephalalgia or headache. 

Cephalalgia. — Cephalalgia is a symptom, not a disease. And I have 
introduced it here for the purpose of inquiring into the morbid conditions 
which it indicates, or of which it is a symptom. Headache may arise 
from disease of the brain, or its membranes ; or it may be sympathetic, 
from a local disease in any tissue or organ of the body. 

If headache arise from disease of the brain or its membranes, its cha- 
racter will point out, to a degree of certainty, the seat and character of 
the cerebral disease. Thus, if the dura mater be inflamed the pain is of 
a dull, aching, or gnawing character. If the cephalic pain be acute, 
sharp, and lancenating, it indicates inflammation of the arachnoid mem- 
brane ; while, if it is of a throbbing character, and neither very acute 
or dull, the disease is probably more especially confined to the pia mater 
or vascular membrane of the brain. And finally, if it partake of the 
characters of the three kinds of pain, it is probable that the three mem- 
branes are involved, and perhaps also more or less of the cerebral mass. 
If the headache be confined to one side of the head, or to one temple, it 
is generally of a neuralgic character ; and especially may it be known to 
be neuralgic if it intermits — the paroxysms coming on at regular hours 
each day, or on alternate days. 

When headache is sympathetic of gastric derangement, I have gene- 
# rally noticed that it occurs in the forehead or temples ; and it is often 
attended with a feeling of languor, drowsiness, and more or less dizzi- 
ness, especially if there be acidity of the stomach as a cause. If a pro- 
tracted pain be complained of, in the top or back portion of the head, 
there is probably either irritation at some point along the spinal cord, or 
the patient is suffering from some derangement of the genital organs, 
and most likely, from excessive sexual indulgence or solitary pollution. 

Thus we have some of the important indications which cephalalgia 

furnishes of local and sympathetic diseases. It may also arise from a 

congestive state of the brain, in which case it is of a dull, heavy, aching 

character ; or it may arise from a directly opposite or anemic condition, 

15 



226 DISEASES OF THE NERVOUS SYSTEM. 

in which case there is rather a feeling of lightness than fullness attend- 
ing the cephalic pain. 

Causes. — Any influence capable of producing either disease of the 
brain or its membranes directly, or which may derange any portion of 
the system, either organically or functionally, may be a cause of head- 
ache. Hence, every imprudence may operate either directly or indi- 
rectly; but among the many, those which most frequently operate as 
causes of cephalalgia, are tobacco, drunkenness, gluttony, onanism, 
sexual excesses, self-pollution, irregular eating, fits of anger, constipa- 
tion, and various occupations which require a stooping posture for an 
unreasonable time. 

Pathology. — The great point to be born in mind, in the pathology of 
cephalalgia, is that it depends upon irritation of some portion of the 
nervous tissues, and that it may depend upon directly opposite condi- 
tions ; in the one case the nervous irritation, depending upon congestion 
or an undue amount of blood, while in the other condition there is an 
anemic state, or too little blood supplied to the nervous matter. In 
either case I believe the function of the nervous matter involved is 
equally deranged, but the indications in the treatment are, of course, 
directly opposite ; in the one case requiring stimulation, while in the 
other abstraction of blood or depletion may be necessary. 

Treatment. — As cephalalgia is a symptom, it should not of course ever 
be treated as a disease. But it should be examined as a means of ascer- 
taining the morbid condition upon which the pain depends. And the 
great points to be settled in the examination are, the exact seat and 
nature of the morbid condition upon which it depends, and also the 
causes which are operating to produce the morbid derangement, whether 
it be local or general, functional or organic. 

When the morbid condition is ascertained, and the cause which has 
produced or is producing it is sought out, it should be abandoned; whether 
it be drunkenness, tobacco, licentiousness, gluttony or any other cause, 
and then the morbid condition corrected as far as maybe, by temperance, 
prudence, &c, and also by such other remedial measures as may be indi- 
cated, always keeping in mind the general condition as controlling the 
indication for depletion or stimulation. 

SECTION II.— MENINGITIS. 

By meningitis I mean inflammation of any one or all the membranes 
of the brain. It may, therefore, be of either the dura mater, the pia^ 
mater or the arachnoid membrane, or of all of them at the same time. 

The dura mater, it will be remembered, is a fibrous structure lining 
the interior of the cranium. It also sends processes from its internal 
surface to support and protect the brain ; while from its exterior, pro- 
cesses are sent off to form sheaths for the nerves as they quit the skull. 
Its external surface is rough, while its internal surface is smooth and 
lined by the arachnoid serous membrane. 

The pia mater is a vascular membrane, being composed of innumerable 
vessels held together by a thin layer of areolar or cellular tissue. It is 
the inner membrane of the brain, the whole surface of which it invests, 



MENINGITIS. 227 

dipping into its sulci between the convolutions and forming a fold in its 
interior, the velum interpositum. It also forms folds in the third and 
fourth ventricles and along the longitudinal fissure of the spinal cord. 

The arachnoid membrane is of a serous character, enveloping the 
brain and being reflected upon the inner surface of the dura mater, and 
like other serous membranes is a shut sack. The arachnoid lies between 
the dura mater and the pia mater, the external, covering the convexity of 
the hemispheres. The interior arachnoid is continuous with the exterior, 
and was formerly supposed to penetrate into the ventricles and line their 
internal cavities ; but it is probable that the serous membrane which 
lines the ventricles is not continuous with the arachnoid membrane, the 
arachnoid being reflected inwards upon the venae Galeni for a short 
distance, and then returning to the dura mater of the tentorium. 

Thus we have a glance at the different membranes of the brain, the 
inflammation of which we will now proceed to consider. And though 
they may all be more or less involved in every inflammation of either, I 
am satisfied that the inflammation is generally more especially located in 
some one of the membranes, and shall, therefore, give the symptoms 
peculiar to each. — The dura mater, as we have seen, is a fibrous struc- 
ture, and though it may be involved in every variety of meningeal or 
membranous inflammation, that to which it is by the peculiarity of its 
structure especially liable, is of a rheumatic character. 

Symptoms of Meningitis. — I will take up first the symptoms of in- 
flammation of the dura mater, and then of the pia mater, and finally of 
the arachnoid membrane, and then consider the symptoms attending an 
inflammation of all the membranes occurring at the same time. 

The symptoms of rheumatic inflammatian of the dura mater do not 
differ very materially in the early stages from those of rheumatism affect- 
ing other fibrous structures. It generally occurs at seasons of the year 
when rheumatism prevails, and attacks persons of a rheumatic diathesis, 
and in whom this membrane of the brain is more predisposed than any 
other part of the fibrous structures to take on rheumatic inflammation. 
It may also be the result of metastasis of rheumatism from other and 
less important parts. When not the result of metastasis, its progress 
may be slow, the patient complaining of a dull, heavy, aching pain in the 
head, which, gradually increases from day to day, till it becomes very 
severe. 

The appetite by degrees is entirely lost. The patient is at first rest- 
less and irritable, and finally becomes wakeful, passing his night without 
any rest, complaining more and more of a constant maddening pain, 
which renders him at times, entirely uncontrollable. The face is 
sometimes flushed, and at others of a very pale appearance. The eyes 
are slightly red, and there is intolerence to light. The pulse is at first 
quite frequent, but later it becomes very slow, full and heavy, frequently 
making no more than forty pulsations to the minute. In severe cases, 
there is during the latter stages, almost constant delirium, as is also the 
case when it is the result of metastasis, from other and remote parts. 

If, as sometimes happens in this inflammation, the other membranes 
become involved, the symptoms are materially modified. There is set 
up a high state of febrile action, the eyes become red, the face becomes 



228 DISEASES OF THE NERVOUS SYSTEM. 

flushed, the pulse frequent, full and quick, and there is a peculiar un- 
easiness experienced along the course of the spine, with general restless- 
ness and irritability. Delirium becomes almost constant, and acquires a 
degree of violence resembling the most furious and ungovernable mania. 

In this aggravated state, the face becomes turgid, the eyes wild and 
furious, the carotid beats strongly, vision is imperfect, and the whole sys- 
tem is in a state of restlessness and agitation. Such are the symptom? 
of rheumatic inflammation of the dura mater, and also their modifications; 
when the other membranes of the brain becomes seriously involved in tht 
inflammation. 

The pia mater, as we have seen, is a cellulo-vascular membrane dipping 
into the amfractuosities of the brain, and also extending into its internal 
cavities. Being thus exceedingly vascular, and its vessels being connect- 
ed by a loose cellular tissue, this membrane is peculiarly liable to become 
inflamed. The pia mater is liable to acute active inflammation, in full 
plethoric habits, and especially during the continuance of a high grade 
of febrile excitement, the irritation of its small vessels, as well as of the 
heart and arteries being in such cases attended with increased power of 
action. 

During low typhus fevers, passive inflammation of this membrane is 
liable to occur ; the capillaries and small blood vessels becoming weak, 
and more or less congested ; and when the distension has produced a 
sufficient degree of irritation of the small vessels, inflammation is the re- 
sult, of a more or less passive character ; the irritation of the capillaries 
of this membrane, as well as the irritability of the heart and arteries, 
being attended with diminished power of action. And as the pia mater 
is supplied with branches of the sympathetic nerve, it is probable that a 
good deal of the sympathetic irritation of the brain, especially from irri- 
tation of the alimentary mucous membrane, is received by the pia mater, 
and then communicated to the other cerebral tissues, in all febrile 
affections. 

Inflammation of this membrane, whether active or passive, is generally 
at first attended with a feeling of fullness, and pain in the head ; which 
symptoms are very soon followed by nausea, and sometimes vomiting. 
As the pain and febrile reaction increase, the eyes becomes red ; the face 
flushed ; the pulse frequent, and there follows a general state of excite- 
ment and irritability. 

Delirium is generally an early attendant, and in many instances soon 
acquires a degree of violence, resembling the most furious mania. 

The face becomes turgid ; the eyes wild and furious ; the carotids may 
beat strongly ; vision is imperfect, and the whole system is in a state of 
restless agitation. 

During the early part of the disease, the sense of hearing may be 
painfully acute ; but in the latter stages, deafness often occurs. Respi- 
ration, though hurried at first, becomes slow and laborious in the latter 
stages ; and in many cases deglutition is performed with more or less 
difficulty. The various organs become deranged ; the liver frequently 
pouring out a copious secretion of acrid bile. And not unfrequently 
hemorrhages from the bowels occur towards the termination of fatal cases. 

The arachnoid membrane, as we have seen, is of a serous character, 



MENINGITIS. 229 

lying between the pia mater and dura mater ; and its inflammation is 
characterized by the symptoms that attend inflammation of other serous 
membranes. As we have already seen, inflammation of serous mem- 
branes tend strongly to a termination, by effusion of serum ; hence the 
frequency of hydrocephalus, as a consequence of inflammation of the 
arachnoid membrane. And though it is probable that this membrane is 
seldom inflamed, without involving the dura and pia mater, more or less, 
yet it is frequently more especially the seat of meningitis, especially in 
children. 

The commencement of this disease is marked by very great irritation, 
rather than by symptoms of inflammation, the approach being very 
gradual, especially during early childhood. The patient is irritable in 
temper, wakeful, and evinces a repugnance to bright light, on account of 
the sensitive state of the retina. The pupils are contracted; the dispo- 
sition fretful and variable ; young children often crying in a sharp and 
spiteful manner, for very trifling causes. Often when sleeping they may 
start suddenly, and exhibit symptoms of terror, or great fright ; and 
finally they exhibit the most decided and violent dissatisfaction, at every- 
thing which occurs around them. 

This state of irritability continues for a time, and then in some cases 
gradually subsides, without passing into the inflammatory state ; the child 
gradually returning to its ordinary condition of health. If, however, 
some accidental cause supervenes ; such as dentition, cold, or intestinal 
irritation ; the irritation of the arachnoid membrane is increased ; its 
capillaries become irritated, and finally either an active or passive inflam- 
mation in set up, according as the system is in a sthenic or asthenic 
state. 

The patient complains now of pains in the head ; the restlessness and 
irritability of temper increase ; the pulse becomes irritated, quick, tense 
and active ; the countenance is expressive of discontent and suffering ; 
the eyebrows are knit, and the eyes half closed, in consequence of in- 
tolerance to light, and the bowels are either torpid or relaxed, with a 
greenish appearance of the stools. As the disease progresses, the cephalic 
pain becomes more severe, and it may be general, effecting the whole 
head, or it may be mainly in the forehead ; children frequently manifest- 
ing this, by applying the hands to that part. Vomiting occurs, and the 
patient is unable to sleep, tossing about in bed, and throwing the arms 
in every direction, and frequently groaning, as if suffering from the most 
intolerable distress. 

Towards the close of the inflammatory stage, when effusion is about 
taking place, there is frequent sighing, such as I have seldom noticed in 
any other disease, and delirium is a more or less constant attendant. 
The skin, during the continuance of the inflammation, is generally warm 
and dry, and the tongue may remain nearly clean, unless there be 
marked gastric disturbance, in which case it may be covered with a thick 
brown fur. 

After an indefinite period, a new train of symptoms supervene, which 
mark the stage of cerebral oppression. The delirium becomes more 
continuous, the countenance exhibits an aspect of surprise and stupor, 
the pupils are either dilated or contracted, the conjunctiva becomes red- 



230 DISEASES OF THE NERVOUS SYSTEM. 

dish, the eyes turn up under the upper lids, constant somnolency super- 
venes, and the patient becomes entirely inattentive to surrounding ob- 
jects. The mind becomes torpid, and incapable of any attention, and 
the drowsiness increases till a complete state of coma occurs. In some 
instances the coma occurs suddenly, with paralysis of a limb or one side. 
In other cases of inflammation of the arachnoid membrane, only slight 
febrile excitement is developed, the drowsiness being almost the first 
manifestation of the disease. In such cases the inflammation is of a 
passive character, and has passed through its stages without developing 
much pain, or any considerable degree of febrile excitement. 

Generally before the occurrence of paralysis, one hand will be firmly 
clenched, and the thumb turned in upon the palm. The upper eyelids 
too may become paralyzed, and strabismus may occur. When effusion 
takes place, if it occurs, all the more violent symptoms may abate, and 
friends may be deceived into the belief that the patient will recover. 
But sooner or later convulsions supervene, or the patient passes into a 
state of fatal coma or stupor. During this stage the pulse becomes slow, 
and often irregular, and both seeing and hearing are sometimes totally 
lost. 

I have spoken of arachnitis as terminating in effusion of serum, and it 
is most probable that such is generally the case, especially if, as gene- 
rally happens, the serous membrane lining the ventricles becomes in- 
volved in the inflammation. It should be remembered also that while 
the arachnoid membrane is the more special seat of the inflammation in 
such cases, it is generally by no means the exclusive seat, the other 
membranes, and especially the pia mater, becoming more or less in- 
volved in the inflammation. 

Thus we have at a glance the more special and important symptoms 
developed in inflammation of the fibrous, vascular and serous membranes 
of the brain. Let us now, bearing these peculiarities in mind, inquire 
into the symptoms which are developed when all these membranes be- 
come alike inflamed, at the same time, or so nearly so, that a distinction 
may not be made between them. The ordinary symptoms of general 
meningitis are restlessness, loss of appetite, depression of spirits, vertigo, 
headache, thirst, and as febrile excitement with the local inflammation are 
fully developed; there is violent headache, the face and eyes become red, 
there is a wildness of expression, giddiness, intolerance to light and sound, 
and the pupils are sometimes almost closed. 

Later, the patient becomes restless, his movements are spasmodic, de- 
lirium more or less violent occurs, the pulse is frequent, hard, and per- 
haps irregular, the respiration difficult, the skin hot, but perhaps moist, 
and the tongue is often clammy, or covered with a lightish colored fur. 
Vomiting too generally attends from the commencement, and the bowels 
are generally, though not invariably, in a constipated state. 

At a later period still, the delirium yields to stupor, and soon the 
patient becomes decidedly comatose. The pupils become dilated, the 
patient neither sees or hears, the surface becomes less sensitive, the 
muscles become rigid, the movements become convulsive, there is picking 
at the bed-clothes, the pulse becomes slow and intermittent, the respira- 
tion difficult, and finally with partial paralysis, the pulse becomes feeble, 



MENINGITIS. 231 

the skin cold and clammy, the features cadaverous, and the patient 
usually dies either in convulsions, or in a state of profound coma or insen- 
sibility. Such are the ordinary symptoms of general meningitis. But it 
must be remembered that in many cases of this character, the inflamma- 
tion not only involves the meninges, but also extends, more or less, to 
the cerebral substance. 

Meningitis may assume a chronic form, or the disease may be chronic 
from the first, in which case the most prominent symptom is that of in- 
sanity. The patient is more or less excited, and is apt to express great 
eagerness in whatever theme may he most prominent in the mind. He 
may be exalted by some vain, ambitious notion, or possessed by some 
monomaniacal propensity, being restless, and talking with very unnatu- 
ral gesticulations. Or the patient may be in an opposite dejected, or 
gloomy mood, being tormented with foreboding apprehensions of some 
imaginary evil. Or the patient may pass suddenly, from very slight 
eauses, out of the deepest gloom into a violent passion of pride, vanity, 
or ambition. 

For a time the functions of the body may be kept up with a tolerable 
degree of regularity, but sooner or later there is a hesitancy of speech, 
or difficulty in pronouncing words ; there is an imperfect control, and 
more or less rigidity of the voluntary muscles, paralysis occurs, and 
finally the sensation of the limbs, as well as motion, is lost. Soon the 
patient loses the power of speech, the sphincters give way, and, finally, 
in a state of idiocy, the patient dies, either paralytic or in the most vio- 
lent convulsions. 

Such are the ordinary symptoms of chronic meningitis. It is liable, 
however, to great variations, like almost every other form of disease. — In 
relation to the duration of meningitis there is a liability of great varia- 
tions. Generally, I think, acute cases may continue from one to three 
weeks, while chronic cases may continue for several months, or even 
years. 

Thus I have completed what I had to say on the symptoms of menin- 
gitis, not only as it occurs in each of the membranes of the brain sepa- 
rately, but also as it occurs in all the membranes simultaneously, both in 
its acute and chronic forms. 

Anatomical Characters. — The dura mater may be thickened, if it has 
suffered from rheumatic inflammation, and in cases of simple inflamma- 
tion, the result of injury, or which has extended from the other mem- 
branes, it may be reddened, ulcerated, or gangrenous, and in some cases 
covered with a layer of lymphs or pus, either on its external or internal 
surface. 

If the pia mater has been the main seat of the inflammation, it is found 
reddened, infiltrated with serum, or pus, and adhering with more or less 
firmness to the brain. I have known this adhesion so strong that por- 
tions of the cortical substance have been torn off, as the pia mater was 
removed from the surface of the brain. 

In cases in which the arachnoid has been the principal membrane in- 
flamed, it exhibits signs of sanguineous congestion, is more or less opaque, 
and perhaps thickened, and more or less covered with pus on both sur- 
faces. There may be found, in some cases, layers of coagulable lymph 



232 DISEASES OF THE NERVOUS SYSTEM. 

on one or both surfaces of the arachnoid, but the most invariable morbid 
appearance presented, if the arachnoid has been highly inflamed, is the 
presence of fluid, of a serous, purulent, or bloody character, in the arach- 
noid cavity, and in the ventricles, if, as generally happens, their lining 
serous membrane has been involved in the inflammation. The quantity 
of the fluid thus found in the ventricles and general arachnoid cavity 
may vary from a few ounces to half a pint or more. But it should be 
remembered that while this is a general, it is not an invariable morbid 
condition following arachnitis. 

If all the membranes of the brain have been inflamed simultaneously, 
the dura mater may be found thickened, reddened, ulcerated, or gan- 
grenous, and the pia mater reddened, infiltrated with serum, or pus, and 
adhering with more or less firmness to the brain, and the arachnoid con- 
gested, opaque, thickened, and perhaps covered with pus or lymph on 
one or both surfaces ; and, finally, more or less bloody, serous, or puru- 
lent fluid may generally be found in the arachnoid cavity, as well as in 
the ventricles of the brain. 

In cases of chronic meningitis, in which insanity is a prominent symp- 
tom, the arachnoid membrane on the surface of the brain, and on the 
inner surface of the hemispheres, is opaque, and thickened so as to re- 
semble the dura mater, being quite as thick, and having in some cases 
false membranes adhering to its cerebral and parietal surfaces. There 
may sometimes be found adhesions between the opposite surfaces of the 
arachnoid. The pia mater, too, is generally found red, thickened, and 
more or less filled with a bloody or serous fluid, and it sometimes adheres 
very strongly to the cerebral mass over which it is spread. In the ven- 
tricles, the pia mater is not only thickened, but its surface is often found 
rough, feeling much as if covered with sand ; and this is also sometimes 
the case with this membrane on the surface of the brain. 

There is generally found, in these cases of chronic meningitis, in which 
insanity is a prominent symptom, an abnormal quantity of serum, not 
only in the ventricles of the brain, but also in the arachnoid cavity, 
amounting, in some cases, to half a pint or more. The serous membranes 
generally are apt to show signs of inflammation, and the disease is often 
complicated during its course with gastro-enteric inflammation. In some 
cases of both acute and chronic meningitis, the brain presents a nearly 
natural appearance, but generally it shows marks of having participated 
in the inflammation, to some extent at least. The brain may, however, 
appear swelled, reddened, congested with blood, and perhaps softened; 
in acute cases, the cerebellum appearing to have participated in the dis- 
ease; while in chronic cases the cerebellum seldom, if ever, appears to 
have been involved in the inflammation. 

Diagnosis. — The diseases with which meningitis is most liable to be 
confounded, are tuberculous meningitis, sympathetic irritation of the 
brain, occurring in enteric and other fevers, and that peculiar anaemic 
state of the brain liable to occur in debilitated conditions of the system, 
and which we see illustrated in delirium tremens. By careful attention, 
however, to the following differences, a correct diagnosis may generally 
be formed. 

Simple meningitis differs from tubercular meningitis, in occurring in 



MENINGITIS. 233 

very young children, while the tuberculous seldom occurs before the 
second or third year, and sometimes much later than that. Simple 
meningitis is often an acute disease, occurring in children of strong or 
sthenic constitutions ; while tuberculous meningitis is slower in its pro- 
gress, is attended with less acute pain and vomiting, and always occurs 
in children or patients of a tuberculous or scrofulous diathesis. 

Meningitis differs from sympathetic irritation of the brain, occurring 
in many fevers; by the pain in the head and vomiting being more con- 
stant ; and by the want of development in sympathetic cases, of several 
important symptoms, such as sighing, clenching of the hands, convulsions, 
paralysis, &c. ; all of which differences, together with the history of the 
case, may render the diagnosis probable at first, and in the latter or more 
advanced stages perfectly certain. 

From an anasinic condition of the brain, such as occurs in debilitated 
conditions, as in delirium tremens, meningitis may be distinguished by 
the history of the case, and by the following differences : In meningitis, 
the face is flushed, the skin often hot and dry, and the patient apparently 
quite strong, resolute and fearless ; while in ansemic cases in which the 
brain is suffering from a want of proper stimulus, the face is pale, the 
surface cool, the pulse feeble, and the patient, instead of appearing 
strong, resolute and fearless, is feeble, tremulous and timid; being often 
tormented with the most ridiculous apprehensions of danger. 

In discriminating between chronic meningitis and chronic anaemic 
cases attended with cephalic and general nervous irritability, the history 
of the case, together with the constitutional predisposition, and all the 
symptoms which are developed, will generally point to a correct diagnosis 
which may be of very great importance, as the treatment proper in the 
two conditions might be widely different. 

Causes. — The predisposition to meningitis may depend upon directly 
opposite conditions of the system ; in active acute cases arising from a 
sthenic, while in passive and chronic cases it may be the result of an 
asthenic or feeble condition of the system. A rheumatic or gouty dia- 
thesis also probably strongly predisposes to certain forms of meningitis. 
Meningitis probably occurs most frequently between the ages of ten and 
forty years, though it may occur in children much younger or in persons 
of a more advanced age. 

Overeating, or the free use of alcoholic liquors, or any other excesses, 
such as great mental excitements, may, by temporarily elevating the 
system above a medium of excitability, act as causes of acute active me- 
ningitis. It may also be produced by injuries, especially in children, 
and it doubtless sometimes arises from sympathy with intestinal irrita- 
tion, and also from dentition. 

Chronic meningitis may arise from any cause which depresses and per- 
manently debilitates the system, such as indigestion from irregular eat- 
ing, and self-pollution in children and young persons, venereal excesses, 
protracted drunkenness, licentiousness, and the use of tobacco in adults; 
and, in short, everything which weakens the blood, and relaxes and irri- 
tates the solid tissues of the body. Chronic meningitis may thus arise, 
or it may be the result of the acute form of the disease. 

Active cases may occur during any inflammatory grade of fever, and 



231 DISEASES OF THE NERVOUS SYSTEM. 

especially of the exanthematous fevers, such as scarlatina, erysipelas, 
&c. In such cases, the irritation set up in the minute capillaries of the 
meninges, as well as that of the general circulatory system being attended 
with increased power of action. 

Passive meningitis may also occur during any of the low forms of the 
exanthematous or other fevers, the irritability or irritation of the menin- 
geal capillaries, as well as that of the heart and arteries, being attended 
with diminished power of action. 

Treatment. — The indications in the treatment of meningitis are very 
plain, whether one or all the membranes are involved. In rheumatic in- 
flammation of the dura mater, involving more or less, of course, the other 
membranes, if it be acute, general bleeding may be required, after which 
the head should be elevated, and the feet placed in warm water, if the 
patient can bear it, morning and evening. A full dose of calomel, or if 
that be contra-indicated, of podophyllin should be given at once, and 
followed, if necessary, in six hours by the sulphate of magnesia, and a 
free operation secured. After general bleeding, when that is indicated, 
or at first, when it is not, three or four ounces of blood may be taken 
from the back of the neck, by cups, and afterwards a blister applied. 

After the operation of the cathartic a diaphoretic of Dover's and 
James's powders, of each three or four grains, may be given every six 
hours, and the patient immediately placed on the use of the iodide of 
potassium, in full doses. Ten grains of the iodide may be given, well 
diluted, every six hours, alternating with the antimonial and Dover's 
powder, and continued till the disease is entirely removed ; which may 
take, according to my experience, from one to two weeks, or perhaps 
longer. 

In cases in which the rheumatic meningitis is the result of metastasis 
of rheumatism, from some other part, occurring from great debility of 
the patient, the general bleeding should be omitted, and perhaps the wet 
cupping, and two or three grains of quinine given every six hours, with 
the antimonial and Dover's powders. In other respects the treatment 
should be the same. Toast water should be allowed at first, and soon a 
plain, digestible diet should be given, and continued through the whole 
course of the disease, if the stomach will bear it. 

In this way I have succeeded in arresting rheumatic inflammation of 
the meninges of the brain, involving no doubt, in some instances the 
fibrous structure of the brain itself. The iodide of potassium should be 
continued, however, in diminished doses, for one or two weeks after the 
disease is arrested, for the purpose of removing the effects of the 
disease. 

Inflammation of the pia mater, of an active character, coming on 
during an inflammatory grade of fever, or developing a high degree of 
febrile excitement, may require active treatment. General bleeding may 
be required in strong plethoric cases, to lessen the violence of the arte- 
rial action, and to relieve the irritated capillaries of the suffering mem- 
brane. After bleeding and cupping, if necessary, ten grains of calomel 
should be given, and followed in five or six hours by a full dose of the 
sulphate of magnesia. 

After the operation of the cathartic, to reduce arterial action, and 



MENINGITIS. 235 

promote perspiration, one-fourth of a grain of tartar emetic, or four 
drops of the fluid extract of the veratrum viridi, may be given every 
three hours, and continued till the general fever and local inflammation 
are subdued. 

The warm foot-bath should be used, and sinapisms applied to the feet, 
and, if necessary, a liberal blister applied to the back of the neck. Toast 
water should be the nourishment at first, and later arrow-root, and finally 
toast may be allowed. Light and every other exciting agent should be 
excluded from the sick chamber, during the continuance of the febrile 
excitement. 

In cases of passive inflammation of the pia mater, occurring in low 
fevers, or in very debilitated patients, depletion is not indicated. In 
such conditions, an elevated position of the head, blisters to the back of 
the neck, and sinapisms to the extremities, with quinine and camphor 
internally, and proper nourishment, constitutes the course of treatment 
clearly indicated. 

In inflammation of the arachnoid membrane, the treatment to be 
effectual must be early applied. During the first stage of irritability 
attention should be directed to the cause of the irritation, and, if possi- 
ble, it should be removed, whether it be from intestinal worms, indiges- 
tion, dentition, or any other cause. But if inflammation becomes estab- 
lished, general or local bleeding may be necessary, in active cases, after 
which a cathartic of calomel or podophyllin should be administered, and 
then small doses of calomel with James's powder may be given, and 
continued every four hours, during the active stage of the disease. 

The head should be kept high and cool, and the feet warm, and blisters 
applied back of the ears, or to the back of the neck, and if the small 
doses of calomel does not keep the bowels loose, small doses of castor oil 
should be administered, once every twenty-four hours. After the mer- 
curial impression is produced the calomel should be discontinued, and 
full doses of the iodide of potassium given every four or six hours, alter- 
nating with the James's powder, and continued during the whole course 
of the disease, for the purpose of preventing effusion into the ventricles 
of the brain, or into the arachnoid cavity. 

Blisters should be applied to the temples, back of the ears, or to the 
back of the neck ; and the patient should be sustained early by toast 
water, with, perhaps, a little arrow-root or crust coffee. Thus we have 
the treatment proper for inflammation of each of the membranes of the 
brain, whether it occurs in an active or passive form, the principles of 
which may guide us in the treatment of meningitis, involving all the 
membranes simultaneously, both active and passive. 

In acute general meningitis, then, our main reliance must be on general 
or local bleeding, the warm foot-bath, sinapisms to the extremities, 
cathartics, alteratives, arterial sedatives, diaphoretics, blisters, low diet, 
&c. ; keeping, of course, an eye upon the general condition of the patient, 
whether the system be in a sthenic or asthenic state. 

In general chronic meningitis, in which insanity is a prominent symp- 
tom, a careful removal or avoidance of the cause, or causes, which have 
been operating, a regulated diet, and strict observance of all the laws of 
health, together with tonics, if the patient be anaemic, and dry cupping, 



236 DISEASES OF THE NERVOUS SYSTEM. 

or blisters to the temples or back of the neck, &c, involve the principles 
upon which our main reliance is to be placed. Thus we have the prin- 
ciples which are to guide us in the treatment of every variety of men- 
ingitis. 

SECTION III.— CEREBRITIS. 

By cerebritis I mean inflammation of the cerebral substance, which, if 
only partial, may be exclusive of meningitis, but which if quite general 
is apt to involve to some extent the meninges of the brain. — The brain 
includes properly those parts of the nervous system, exclusive of the 
nerves, which are contained within the cranium, embracing the cerebrum, 
cerebellum and medulla oblongata. The cerebrum, it will be remem- 
bered, consists of two lateral hemispheres, which are divided inferiorly 
into an anterior, middle and posterior lobe ; beneath which posterior 
lobe is the cerebellum lodged in the posterior fossa of the base of the 
cranium. 

The medulla oblongata appears like an enlarged portion of the spinal 
cord. It is slightly conical in shape, about an inch in length, and 
extends from the pons varolii to the upper border of the atlas, being 
the tract of communication between the brain and spinal cord. It is 
probable that its anterior portions convey motor influences, while its 
posterior convey sensations. And besides, the medulla oblongata acts as 
a nervous centre, as respiration and deglutition depend upon it. 

We have already seen that the brain has certain cavities, the lateral, 
third and fourth ventricles, and that its structure consists of an external, 
gray, vesicular substance, and an internal, white, fibrous, tubular matter, 
and that it is supplied with blood by the carotid and vertebral arteries. 
Thus constituted the brain is liable to partial or general inflammation of 
its substance, either complicated with, or exclusive of, inflammation of 
its membranes. 

Symptoms. — Inflammation of the brain may, in some cases, pass on to 
destruction of its substance, or at least some parts of it, before any very 
marked symptoms are developed. Generally, however, there is at first 
a fixed and violent pain in the head, which may continue for several 
weeks or even months. There is also vertigo obtuseness of the mental 
functions, confusion of the ideas, loss of memory, hesitancy in answering 
questions or partial loss of speech; and the patient not unfrequently 
becomes dejected and difficult or else indifferent to surrounding objects. 

There may be numbness of the extremities, perverted vision, and in 
some cases total blindness occurs. The hearing also is apt to become 
either dull or acute, the epigastrium tender, the bowels constipated, and 
the appetite variable. The pulse may be full but it is liable to great 
variations, being often slow, irregular and exceedingly variable. Thus 
the symptoms are gradually developed during the first stage, the headache 
continuing often with unabated violence till a new train of symptoms are 
developed during the second stage of the disease. 

The symptoms developed thus far, are probably the result of conges- 
tion, irritation, and slow inflammation : but as softening of the cerebral 
substance takes place, there is rigidity, and in some cases continuous 



CEREBRITIS. 237 

spasm of the flexor muscles of some part of the body, as of the limbs, 
or perhaps of a single muscle, or possibly symptoms of paralysis of sensa- 
tion or motion, or both may occur. 

In one fatal case of this disease which fell under my care, during the 
second stage, the patient had suffered from intolerable pain in the head 
for several months, during the first stage of the disease. And, though 
with the softening process, or second stage, there was only a hesitancy of 
speech, with inability to connect words to form a sentence, in attempting 
to answer questions, or express his ideas ; he was seized suddenly with 
convulsions of the flexor muscles of the limbs, and died after two or 
three days of the most profound coma. In some cases, however, the 
second stage is merged in one of paralysis ; the limbs which were before 
flexed with violent contractions of their muscles, now become perfectly 
paralyzed, losing all sensation, and power of voluntary motion. 

In such cases, the affected portion of the brain has generally passed 
into a disorganized state, being either in the last stage of softening, or 
thoroughly dissolved into pus. The patient finally loses the senses of 
sight, hearing, &c, and by degrees, the different functions of the body, 
become suspended, till at last he dies^ having been reduced to the extreme 
of physical and mental weakness. 

Thus we have the symptoms of cerebritis, as they are generally de- 
veloped : but it must be remembered, that the disease is liable to great 
variations. In some cases, if the inflammation be quite general, and 
violent, convulsions may occur in a few days, from the first attack, or 
after a short period of headache, with slight febrile excitement, coma may 
supervene, and the patient may die in one or two weeks, without having 
had any considerable convulsions. 

Generally, however, the disease is of a chronic character ; being 
marked as I have said, by three distinct stages, of variable duration. 
During the first stage, it should be remembered, while the inflammatory 
process is going on, violent pain in the head is the most prominent 
symptom. During the second stage, while the process of softening, or 
suppuration is going on, the pain in the head may subside ; and instead, 
the patient be tormented with irregular action of the muscles, and more 
or less paralysis, or partial loss of voluntary motion, and sensation, of 
different parts of the body. And finally, during the third stage, when 
the brain has become completely disorganized, there is stupor, paralysis, 
and a gradual suspension of the voluntary and vital functions, till at last 
the patient dies, after having suffered for an indefinite period, varying 
from a few weeks, to several months, or perhaps years. 

Anatomical Characters. — In cases of cerebritis, which are rapid in 
their course, and quite general, congestion of the diseased portion of the 
brain is generally found, and often the meninges of the brain show signs 
of having been more or less involved in the inflammation. In cases in 
which the brain alone has been inflamed, its substance is found changed 
at the point of disease, which may be any portion of the cerebral mass ; 
but I believe it is most frequently in the external gray vesicular substance. 
The character of the morbid change, varies also with the stage of the 
disease, at which death occurs ; and also somewhat with its location, 
whether it be in the vesicular, or white tubular portion. 



238 DISEASES OF THE NERVOUS SYSTEM. 

If the patient dies daring the early stage, numerous red points may be 
seen, and the brain may be found of a red, violet or brown color, and it 
is generally softer, though it may be harder, than in a state of health. 
In advanced stages of the disease, pus is found infiltrated into the brain, 
or what is more probable, the substance of the diseased brain is found 
converted into pus. At least, the structure of the brain, at the diseased 
point, has the appearance of being dissolved into pus, by which it is 
colored of a brown or greyish color, the mass being apparently a mixture 
of blood, pus, and dissolved cerebral substance. Finally, if the patient 
has passed on to the third stage of the disease, no trace of blood or even 
of the cerebral substance may be found, nothing but pus occupying the 
diseased part. 

In some cases, the cerebral substance is found softened, without any 
appearance of pus. Especially may this be the case, if the disease has 
been located in the medullary portion of the brain, in which case the 
softened cerebral substance is sometimes found of a milk white color, 
and without any apparent mixture of pus or blood. 

It is well to bear in mind then, that if death occurs during the early 
stage, the diseased part presents a congested appearance. At a later 
period there is found more or less softening, with purulent infiltration. 
And, finally, if the patient passes into the third stage, clear pus is gene- 
rally found, if the disease be of the cortical substance, though white soft- 
ening may be found, if the disease has been of the medullary substance 
of the brain. Induration may, however, be found in some rare cases, 
and so may gangrene; the diseased part in the latter case, presenting a 
livid softened appearance, having a fetid odor, and being mingled with a 
very offensive greenish liquid. 

Thus we have the principal morbid appearances presented in the diffe- 
rent stages of cerebritis, but it must be remembered that obstruction of 
the cerebral arteries sometimes leads to softening of the brain, in cases 
in which no cerebral inflammation has occurred. In such cases, how- 
ever, no granules or granular corpuscles are found in the softened mass, 
while if the softening be the result of inflammation, they may be detected 
by the microscope, " resulting from the exudation of the inflammatory 
process." 

Diagnosis. — Cerebritis may be confounded with meningitis, hysteria, 
and apoplexy; from which, however, it may be distinguished by careful 
attention to the following differences. 

From, meningitis this disease differs by being attended with less fever, 
less acute delirium, or general convulsions ; by being attended with more 
rigidity and tonic spasm in the latter stages of the disease, especially of 
the flexor muscles, and finally by the much greater duration, as cere- 
britis may continue for several weeks, months, or even years. 

Cerebritis differs from hysteria in the violent protracted pain in the 
head, which does not necessarily occur in hysteria, in the distressing and 
often protracted vomiting, and also in not being so generally attended 
with alternate laughing and crying, as is apt to be the case in hysteria. 

From apoplexy, cerebritis may be distinguished by the history of the 
case, by the pain, vomiting, and rigidity of the flexor muscles in cere- 
britis, and by its generally occurring in more anaemic patients than 
apoplexy. 



CEREBRITIS. 239 

Causes. — The causes of cerebritis are various, such as imprudence in 
eating, drunkenness, the suppression of some habitual sanguinous dis- 
charge, the depressing mental emotions, the use of tobacco, and also in- 
dulgence in vinous and other fermented liquors. It is probable, how- 
ever, that masturbation, and venereal excesses, constitute by far the 
most frequent causes of cerebritis. By these and like causes, the sub- 
stance of the brain becomes involved in a slow passive inflammation, 
which may terminate in softening, suppuration, and other varieties of 
morbid conditions, affecting in some cases a very limited amount of the 
cerebral mass, while in others, a whole hemisphere may become involved. 

Prognosis. — Cerebritis is always attended with considerable danger. 
If, however, the cause can be ascertained and removed, and the patient 
can be brought to conform, rigidly, to the laws of health, and can have 
the benefit of a careful judicious treatment during the early stages, the 
patient may very much improve, and perhaps entirely recover. If, how- 
ever, the disease is very extensive, and has passed on to the third stage 
of softening, or suppurative disorganization, the case may be expected to 
terminate fatally; the only hope in such a case being that the disor- 
ganized part may become inclosed in a cyst, and thus lessen its serious 
effects, till finally it may be absorbed. 

Treatment. — In acute cases of cerebritis, if the inflammation be quite 
general, or slight bleeding from the arna, and cupping about the temples 
or back of the neck may be indicated, after which a cathartic of calomel 
or podophyllin should be given, and a reasonable operation secured. The 
warm foot-bath should be used morning and evening, if the patient can 
bear it, and gentle diaphoretics, such as ipecac, antimonials, sage tea, 
&c, given, taking care, however, not to increase the nausea, if that be 
already troublesome. If, however, the case becomes chronic, as it often 
does, the indications are the same as those which exist in cases chronic 
from the first, the treatment of which we will now proceed to consider. 

In all chronic cases of cerebritis, in which the inflammation is generally 
of a passive character, the depressing or debilitating cause should be 
sought out and removed, if possible; whether it be tobacco, drunkenness, 
self-pollution, venereal excesses, indulgence in fermented liquors, or any 
other cause. Cups, wet or dry, according to the degree of debility, 
should be applied to the temples or back of the neck, and repeated if 
necessary, once or twice a week at first, but later, instead, blisters should 
be applied to the temples, back of the ears, or back of the neck ; and 
this should be kept up during the whole course of the disease. The 
bowels should be kept gently loose during the early stage of the disease, 
by an occasional blue pill, or if that be contra-indicated, small doses of 
podophyllin or leptandrin. In the more advanced stage, however, a pill 
of aloes and rhubarb, of each one and a half grains, I believe will gene- 
rally do best. 

The patient should be restricted to a plain, digestible, and moderately 
nourishing diet, to be taken with strict regularity; or if the patient be 
decidedly ansemic, a good, nourishing diet should be allowed, and the 
citrate, carbonate, or syrup of the iodide of iron given and continued in 
moderate doses for a long time. The patient should be directed to take 
a reasonable amount of exercise ; to keep the head well elevated and cool 



240 DISEASES OF THE NERVOUS SYSTEM. 

and the feet warm and dry; but violent exercise, either of body or mind, 
should be strictly prohibited, and a fit of anger should on no account be 
indulged in. 

In very protracted cases, in which a small cyst may have formed, con- 
taining pus, the absorption of which is desirable, five grains of the iodide 
of potassium may be given three times per day, before each meal, and 
continued for a long time. In cases in which the disease has been re- 
moved, if the brain remains in a torpid, inactive state, indicated by de- 
rangement or an impaired state of the functions of the body, some pre- 
paration of the nux vomica may be indicated ; in such cases, a grain of 
the muriate of strychnia may be dissolved in six or eight ounces of water, 
and a teaspoonful given three times per day till the tone of the nervous 
system is restored. 

SECTION IV.— TUBERCULOUS MENINGITIS. 

By tuberculous meningitis I mean inflammation of the membranes of 
the brain, involving, to some extent, the cerebral substance, and being 
attended with tubercles in the pia mater, and always occurring in patients 
of a scrofulous or tuberculous diathesis. This disease may occur at any 
age, but it most frequently occurs during childhood ; and from the fact 
of its terminating so often in the effusion of serum into the ventricles, it 
has been called acute hydrocephalus ; but in some cases of this disease 
no serous effusion takes place into the ventricles. 

Symptoms. — In scrofulous children, or adults, in which this disease is 
being developed, there may be a protracted stage of premonitory symp- 
toms, such as irritability, slight fever, paleness, emaciation, and various 
dyspeptic symptoms. There may be also occasional headache, with 
vomiting coming on irregularly, or at regular hours each, or every other 
day ; and these symptoms may be gradually aggravated till inflammatory 
symptoms are developed. 

After these premonitory symptoms have continued for an indefinite 
period, when they occur, or are noticed, and at first when they are not 
visible, the patient is seized with pain in the head, and vomiting, which 
may occur two or three times during every twenty-four hours for the first 
three or four days before the patient takes his bed. Slight chills may 
precede the febrile excitement. In either case, when the disease be- 
comes established, the pain in the head becomes almost constant, being, 
however, greatly aggravated at times. The pain is most frequently felt 
in the forehead or temples, &nd is indicated in young children by a fre- 
quent application of the hand to the fore part of the head. The vomit- 
ing is apt to occur with the aggravation of the pain, and not unfrequently 
with the food more or less bile is ejected. This symptom may subside in 
three or four days, or it may continue much longer than that. 

There is often pain in the abdomen, and constipation at first, or if the 
bowels are loose, the stools are generally of a dark greenish color, ac- 
cording to my observation. The pulse may be slightly excited, but the 
face is apt to be pale, except during the paroxysms of severe pain. 
There is little thirst, and the tongue may be moist, and only slightly 
furred. The eyes are sensitive to light, the pupils either contracted or 



TUBERCULOUS MENINGITIS. 241 

dilated, and the child becomes peevish, fretful, and perhaps at times 
slightly delirious, even during this first stage of the disease. 

As the disease passes into the second stage, more decided symptoms 
supervene. The pulse may become slower, but it is very irregular, and 
often intermittent. The respiration becomes irregular, is slower than in 
the first stage, and I have generally noticed frequent and deep sighing. 
By degrees the skin becomes cool, and partial sweating occurs, the 
patient becomes drowsy, often moaning, or sending forth sharp screams, 
or else is delirious, being wild, and sinking in two or three days into 
profound coma. 

One hand is apt to become clenched, with the thumb pressed into the 
palm; the eyes turned up, or else either in or out, and the pupils 
dilated; vision is impaired or lost, and the patient evidently without 
taste, swallows, if able, anything placed in the mouth. Thus the patient 
may continue for a week or more, with perhaps periods of marked remis- 
sions, till a third stage, indicating more profound cerebral lesion super- 
venes. 

In this third stage of the disease, there is more or less tonic spasm of 
some of the flexor muscles, generally of one of the extremities; the jaws 
may be closed, the head turned back, and not unfrequently there are 
violent convulsive movements. Finally, paralysis takes place in some 
one of the extremities, the surface becomes insensible, sight and hearing 
are lost, profound coma supervenes, the pulse becomes more irregular and 
frequent, the eyes become dim, the surface cold, and the patient finally 
dies either in a state of profound coma, or in violent convulsions. 

Thus we have the ordinary course and symptoms of tuberculous me- 
ningitis, but it must be remembered, that like every other disease, it is 
liable to great variations, according to the general condition of the 
system, and the character of the meningeal inflammation. These cir- 
cumstances also materially affect the duration of the disease, which may 
vary from five or six days to six or eight weeks. Generally, however, I 
think the patient may survive two or three weeks, after the supervention 
of the violent headache, vomiting, &c. 

Anatomical Characters. — There is found, on post-mortem examination 
in these cases, minute, gray, white, or yellowish granules, or tubercles, 
varying from the merest speck to the size of a mustard seed, and being 
dispersed over the surface of the cerebrum and cerebellum, in the sub- 
stance of the pia mater. In some cases, however, they may be confined 
to a small spot, or to one of the hemispheres ; out I believe they are 
more generally diffused on the lateral portions, base, anfractuosities, 
and fissures of the brain, filling up more or less the loose tissue of the 
pia mater. In some cases the tubercles are of much larger size, or seve- 
ral of them may be aggregated together, including the pia mater in their 
substance. 

The arachnoid membrane on its free surface may appear nearly natu- 
ral, but it is sometimes slightly thickened, and occasionally it contains a 
little serum in its cavity. Marks of inflammation are almost always ex- 
hibited by the pia mater, as it is thickened, and infiltrated more or less 
with a turbid fluid, or a concrete matter is deposited in its tissue, con- 
sisting, probably, of coagulable lymph or concrete pus. This concrete 
16 



242 DISEASES OF THE NERVOUS SYSTEM. 

matter may generally be found either in patches, or in lines close along 
the blood-vessels, and being interspersed more or less with many tubercles. 

The brain itself may appear flattened, and the cortical substance red- 
dened, and perhaps softened, while the medullary portion may be covered 
with minute red specks, and the same appearances are presented, if it be 
cut through. In some cases no more than a natural quantity of serum 
is found in the ventricles, but generally from an ounce to half a pint or 
more of serum may be found in the ventricles, the result, probably, of 
inflammation of their lining membrane, its appearance being modified, 
and its quantity increased by the softening of the brain which occurs, as 
the medullary substance bounding the ventricles is often found softened 
to a creamy consistence. Tubercles are generally also found in other 
parts of the body, thus rendering it certain that this disease is the result 
of a general tuberculous condition of the system. 

Diagnosis. — Tuberculous meningitis differs from simple meningitis in 
the following particulars, by which it may be distinguished. Tubercu- 
lous meningitis always occurs in patients of a tuberculous or scrofu- 
lous diathesis, and seldom occurs in children under two years of age, 
while simple meningitis may occur in early infancy, and in patients of a 
strong vigorous constitution from various exciting causes. 

In simple meningitis, the disease is liable to be more acute and sudden 
in its attack, and to be attended with more fever, heat, thirst, delirium, 
vomiting, and to be more continuous and rapid in its course than the 
tuberculous disease. Besides, tuberculous meningitis may pass on from 
three to six weeks, before a fatal termination takes place, while simple 
meningitis often terminates by the seventh or eighth day, though it may 
continue longer. 

From certain conditions of congestion and irritation of the brain, oc- 
curring in enteric and other fevers, tuberculous meningitis may be dis- 
tinguished by the history of the case, by the absence in the febrile affec- 
tion of the violent paroxysmal pain, and vomiting, of the clenching of 
the hand, and deep sighing, and finally, by the want of the spasms and 
paralytic symptoms, which attend tuberculous meningitis. By careful 
attention to all these differences, I believe a correct diagnosis may gene- 
rally be formed in tuberculous meningitis, 

Causes. — It is probable that this disease is often hereditary, as tuber- 
culous diseases are apt to be. Children born of tuberculous parents, 
with large heads and short necks, are peculiarly liable to become affected 
with meningeal tuberculous disease as the brain or its membranes in such 
cases is most prone to become the seat of the tuberculous deposit. Va- 
rious causes may, however operate to produce this disease, in children or 
adults, in whom no decided hereditary predisposition to the disease 
existed. • 

In children, this disease may be produced by exposure to damp apart- 
ments, by insufficient clothing, by irregularity in taking food, and by 
any and every cause capable of impairing digestion, reducing the blood, 
and at the same time tending to congestion and irritation of the brain or 
its meninges. In adults, tuberculous meningitis may be produced by the 
causes enumerated above, together with the use of tobacco, drunkenness, 
masturbation, licentiousness, and every other cause capable of impairing 
the blood and of increasing cephalic congestion and irritation. 



TUBERCULOUS MENINGITIS. 243 

In children or adults in which there is the scrofulous or tuberculous 
diathesis, it is probable that slight causes may develop the disease, such 
as falls, dentition, the healing of sores of the scalp, intestinal irritation 
from irregular eating, and worms, in children and adults ; in addition to 
all these causes, great mental excitement, exposure to solar heat, various 
occupations, fits of anger, &c. 

Pathology. — It is evident, that in every case of this disease, there is 
a scrofulous or tuberculous condition of the system, and generally tuber- 
culous deposits, not only in the pia mater, but in other tissues of the body. 
Now it is probable that in many cases, tubercles are deposited in the pia 
mater, from slow congestion and irritation of the meninges of the brain, 
and as the tubercles accumulate they increase the irritation, and finally 
develop, with some slight accidental cause, meningeal inflammation. In 
other cases, slight inflammation may exist from the first, and only be in- 
creased by the tubercles, till by the addition of some accidental exciting 
cause or without it, meningeal inflammation is fully developed, and being- 
complicated with the tuberculous disease, passes on often in spite of reme- 
dies, to a fatal termination. 

It is probable that the serous membrane lining the ventricles becomes 
inflamed, as well as the medullary substance constituting their walls, in 
all those cases of tuberculous meningitis, in which serum is found in 
their cavities and the surrounding cerebral substance is found softened. 
But it is possible that in such cases the serum in the ventricles, may by 
acting upon the medullary substance constituting their walls, produce or 
increase the softening of the cerebral substance. In cases in which no 
more than a natural quantity of serum is found in the ventricles, and in 
the general arachnoid cavity, the presence of the tuberculous matter 
together with the congested and inflamed condition of the brain and its 
meninges, account for the symptoms which are developed. 

Prognosis. — The prognosis in tuberculous meningitis is generally 
unfavorable, especially if the disease has progressed considerably, and 
any considerable amount of tuberculous matter has been deposited in 
the pia mater. It is possible, however, that if the inflammation be slight 
and only a few scattering tubercles have been deposited, that the disease 
may be arrested so that no further tuberculous deposit may take place if 
the inflammation be subdued, and the condition of the blood improved as 
soon as may be. The scattering tubercles in such a case, remaining in a 
latent state, and failing to produce any very considerable local or general 
disturbance for a long time at least. 

A case fell under my care a few weeks since, in this village, in which 
I have reason to believe there was incipient tuberculous meningitis. 
The patient a child two years old, of a scrofulous diathesis, had all the 
early symptoms of this disease ; which, however, appeared to be arrested, 
for the time at least, by cathartics, iodide of potassium, blisters, &c. 
As the more alarming symptoms subsided, a copious eruption of mattery 
pimples appeared upon the scalp and the child, though feeble, exhibits 
now no marked symptoms of the disease. 

Treatment. — In cases which inherit a scrofulous constitution, or in 
which there is an acquired predisposition to this disease, every possible 
care should be taken to prevent its development. The child should be 



244 DISEASES OF THE NERVOUS SYSTEM, 

kept in comfortably warm and dry apartments ; should be allowed food 
only at regular hours, and that of a plain, digestible and nourishing 
character, and should be allowed pure, fresh, dry air, as far as may be. 
If, however, the disease develops itself, more active measures should be 
resorted to. On the first appearance of the symptoms, a cathartic of 
calomel, hydg. cum creta, podophyllin or leptandrin, should be adminis- 
tered, and a free operation secured. The feet should be set in warm 
water morning and evening, and as much irritation kept up to the bottom 
of the feet by mustard applied fresh morning and evening, as the patient 
can bear, and this should be kept up, I am satisfied, during the whole course 
of the disease. Great care should be taken to keep the feet warm, and 
the head elevated and cool. 

As the blood is always in a reduced state in these cases, and the in- 
flammation, consequently of a more or less passive character, I believe 
that general bleeding is seldom, if ever indicated in this disease ; cups, 
however, or leeches, may be applied to the temples, or to the back of the 
neck, and repeated, if necessary, during the early stage of the disease ; 
and later, blisters should be applied back of the ears, and to the back of the 
neck, and repeated at intervals while the disease continues. After the 
operation of the first cathartic, moderate doses of James's powder may 
be given, every six hours, for the first few days, to promote perspiration, 
and lessen the cephalic tendency. 

To correct the scrofulous condition ; arrest the tuberculous deposit, 
and prevent the effusion of serum into the ventricles, and general arach- 
noid cavity, the iodide of potassium, in full doses, should be given 
immediately after the operation of the first cathartic, and continued 
every six hours, during the whole course of the disease. The strength 
of the patient should be sustained from the first, by crust coffee, one 
third, or one half milk, as a drink ; and if the stomach becomes able to 
retain it, mild digestible food should be allowed at meal hours ; at least 
after the inflammation is in a measure subdued. 

The James's powder should be given, alternating with the iodide of 
potassium, till the meningeal inflammation subsides ; after which, if the 
patient is decidedly anaemic, small doses of the citrate of iron may be 
given instead, every six hours, alternating with the iodide of potassium, 
and continued, as well as the iodide, for a long time. It is doubtful 
whether any advanced case of tuberculous meningitis is ever permanently 
cured : but I believe in this way, the disease may often be arrested, so 
that no more tubercles may be deposited ; and thus a check, at least, put 
upon the development of the disease for a time, if not permanently. 

SECTION V.— SPINAL MENINGITIS. 

By spinal meningitis, I mean inflammation of the membranes of the 
spinal cord, in which the medullary substance of the cord, is liable to be, 
though not necessarily involved. The membranes of the spinal cord, it 
will be remembered, are continuous with those of the brain ; consisting 
of the dura mater, pia mater, and arachnoid membranes. Their structure 
is identical with the cephalic membranes, except that the pia mater is 
less vascular, and is of a more fibrous structure, than the pia mater of 
the brain. 



SPINAL MENINIGITIS. 245 

The dura mater, like that of the brain, is the outer membrane, being 
united firmly to the margin of the occipital foramen superiorly, and to the 
coccyx inferiorly ; but in the rest of its extent, it is only connected by a 
very loose areolar tissue, to the walls of the spinal cord. The pia mater 
immediately invests the cord, being a continuation of the pia mater of 
the brain. It sends off duplicatures into the anterior and posterior 
longitudinal fissures, and also a process on each side of the cord, its 
entire length, the ligamentum dentatum, which separates the anterior 
from the posterior roots of the spinal nerves. 

The arachnoid membrane of the cord is continuous with that of the 
brain, and encloses the cord very loosely. It lies between the dura mater 
and pia mater, forming the outer serous covering of the pia mater, pass- 
ing off with the other membranes to form a sheath for the nerves, and 
then being reflected on the inner surface of the dura mater, thus giving 
it a serous lining, and constituting the arachnoid cavity of the cord a 
shut sac, similar to that of the brain. 

The arachnoid cavity of the cord, like that of the brain, is occupied by 
a serous fluid, which expands the arachnoid, and keeps up a gentle pres- 
sure, which yields with facility to the various movements of the cord. 

Now it must be remembered, that all these membranes pass off toge- 
ther, to form sheaths for the spinal nerves. And further, that the pia 
mater is supplied by a number of plexuses, derived from the sympathetic 
system of nerves. Now the spinal meninges, thus constituted and 
arranged, are liable to become inflamed, the simple inflammation of 
which we will now proceed to consider. 

Symjrtoms. — Spinal meningitis maybe either acute or chronic; the 
symptoms, of course, varying with the intensity of the inflammation. 
The symptoms vary, also, according to the membrane chiefly involved in 
the inflammation. If the dura mater or the pia mater be the seat of the 
inflammation, the pain may be of a dull heavy character, as the pia mater 
of the cord is of a fibrous character, as well as the dura mater. If the 
arachnoid membrane lining the dura mater, or that covering the pia 
mater, become materially involved, or be the special seat of the inflam- 
mation, the pain may be of a sharp lancinating character. 

In spinal meningitis, then, involving as it does, generally, more or 
less, all the membranes, we have pain of either a dull, aching, gnawing, 
or else of a sharp lancinating character along the spine, and extending 
into the limbs, or parts supplied with nerves from the spinal cord. This 
pain is generally increased by motion, and is often attended with tetanic 
contraction, and violent spasms of the muscles supplied with nerves from 
the diseased track, or point of the spine ; and there is also a feeling, 
either in the neck, back, or abdomen, according to the seat of the men- 
ingeal inflammation, as if they were girt by a tight bandage. Besides, 
there is generally constipation, and often retention of urine, with a feel- 
ing of suffocation, and chills, of more or less severity. 

After the chill or chills, more or less fever is developed, the pulse 
being hard and frequent, but perhaps small, the skin hot, but perhaps 
profusely moist, the respiration tedious, &c. Finally, if the disease pro- 
gresses, the pulse becomes irregular and feeble, drowsiness, delirium, and 
coma occur, with paralysis, and involuntary discharges, and at last the 



246 DISEASES OF THE NERVOUS SYSTEM. 

patient dies, at a period varying from one to two weeks from the com- 
mencement of the disease. 

In chronic spinal meningitis, then, there is generally a dull pain in some 
portion of the spine, with more or less deranged sensations in the ex- 
tremities, as well as functional derangement of the thoracic, abdominal, 
or pelvic viscera. After an indefinite time tonic spasms occur, the limbs 
are flexed, the head is drawn to one side or backward, and, unless an 
acute attack supervenes, there may be paralysis, exhaustion, and a 
gradual failure of all the functions of the body, till the patient, worn 
down by wakefulness, irritability, and physical prostration, dies in a 
state of profound coma, having suffered, perhaps, for weeks, months, or 
even years. 

Anatomical Characters. — The membranes of the cord are found thick- 
ened, the dura mater presenting a deeper color than in health, the arach- 
noid is more or less opaque, and the pia mater injected, red, and swelled. 
Turbid serum is found in the lower portion of the arachnoid cavity, and 
more or less lymph or pus is found between the arachnoid and pia mater, 
and also between the pia mater and the spinal cord. 

Diagnosis. — Spinal meningitis may be confounded with myelitis, or 
with rheumatic inflammation of the spinal ligaments, or the surrounding 
muscles. In spinal meningitis, tonic spasms of the muscles, with flexion 
of the limbs, is a prominent symptom ; while in myelitis, paralysis, fol- 
lowing inflammation, is a leading feature of the disease. 

From rheumatism of the spinal ligaments, spinal meningitis may be 
distinguished by the historv of the case, and by the fact that in menin- 
gitis pressure on the spinous processes causes most pain, while in rheu- 
matism of the ligaments, most pain is produced by making pressure along 
the side of the spine. 

Causes. — Spinal meningitis may be produced by direct blows or violent 
straining, by venereal excesses, by atmospheric vicissitudes, by alcoholic 
liquors, and by the metastasis of rheumatism, erysipelas, &c. 

Prognosis. — Spinal meningitis though a dangerous, is by no means 
always necessarily fatal. According to my observation, most cases, if 
attended to properly in season, may be arrested, though I believe one 
attack strongly predisposes to subsequent attacks of the disease. 

Treatment. — In acute spinal meningitis, occurring in strong plethoric 
patients, general bleeding may be indicated, at first, as well as an active 
cathartic of calomel or podophyllin, after which, cups should be applied 
along each side of the spine at the inflamed point, and more or less blood 
taken. 

If the disease becomes chronic, and in all cases which have not assumed 
an acute form, cups, wet or dry, should be applied on each side of the 
spine, at the inflamed point, and repeated every day or two at first, and 
then blisters should be applied, an inch wide, on each side, along the in- 
flamed part, and repeated at intervals of a few days till the inflammation 
is subdued. 

Mild cathartics may be given, such as the blue pill, followed by the 
sulphate of magnesia, or perhaps the podophyllin or leptandrin if the 
mercurial be contra-indicated. 

In all cases of a rheumatic character, or in which there is danger of 



MYELITIS. 247 

effusion into the arachnoid cavity, the iodide of potassium in full doses 
should be given three times per day, and continued till all symptoms of the 
disease are removed; in conjunction with the remedies suggested above. 

SECTION YI.— MYELITIS. 

By myelitis I mean inflammation of the substance of the spinal cord. 
The spinal cord, it will be remembered, is a continuation of the brain, 
extending from the brain, and including the medulla oblongata, from the 
pons varolii to the first or second lumbar vertebra. It passes along in 
the midst of the vertebral canal, which it by no means fills, and exhibits, 
besides the medulla oblongata, two enlargements corresponding with the 
origin of the nerves for the upper and lower extremities. 

The spinal cord presents an anterior and a posterior longitudinal 
fissure, the latter of which terminates in the gray substance of the inte- 
rior of the cord, while at the bottom of the anterior there is a layer of 
the white structure connecting the two lateral portions of the cord. Two 
other lines are observed on each side of the medulla, the anterior and 
posterior lateral sulci, corresponding with the anterior and posterior roots 
of the spinal nerves. 

The anterior lateral sulcus is a mere trace, marked by the attachment 
of the filaments of the anterior roots. The posterior lateral sulcus is 
more plain, being a narrow grayish line derived from the gray substance 
of the interior of the cord. 

Now the anterior lateral columns, comprehending all that part of the 
cord situated between the anterior longitudinal fissure and the posterior 
lateral sulcus are columns of motion, while the posterior columns, situated 
between the posterior lateral sulci and the posterior longitudinal fissure 
are columns of sensation. 

If a transverse section of the spinal cord be made, it appears to be 
composed of two hollow cylinders of white matter, placed side by side, 
and connected by a narrow white commissure ; each cylinder is filled 
with gray substance, which is also connected by a commissure of the same 
matter. The form of the gray substance is that of two curved lines 
joined by a transverse band; the extremities of the curved lines corres- 
ponding with the sulci of origin of the anterior and posterior roots of the 
spinal nerves. The anterior extremities of the curved lines being larger 
than the posterior do not quite reach the surface at the point of origin 
of the anterior roots of the nerves; but the posterior extremities of the 
curved lines of gray matter reach the surface forming a narrow gray 
line ; the sulcus lateralis posterior, the point of origin of the posterior 
roots of the spinal nerves. The white substance of the spinal cord is 
composed of parallel fibres which are collected into laminae and extend 
the entire length of the cord. 

" The spinal cord transmits impressions from the periphery to the brain 
and conversely enables the brain to bring into action the motor nerves." 
If the cord be divided, it interrupts voluntary motion and sensation in 
those parts supplied by nerves from that portion of the cord below the 
point of division, the functions of the parts supplied with nerves from 
above the point of division remaining unimpaired. 



248 DISEASES OF THE NERVOUS SYSTEM. 

It is probable that the transmission of influences upward and down- 
ward, is to a considerable degree accomplished, through the vesicular 
substance, which has the power of transmitting influences, not only in a 
longitudinal but in a transverse direction. But the exterior white fibrous 
structure possesses a like function, the anterior columns being motor, and 
the posterior sensory, at least, in a longitudinal, if not in a transverse 
direction. 

There are nine pairs of cranial nerves, and thirty-one pairs of spinal 
nerves. The spinal nerves, as we have seen, arise by two roots, an an- 
terior motor and a posterior sensitive ; the anterior proceeding from a 
narrow white line, the anterior lateral sulcus, while the posterior pro- 
ceeds from the posterior lateral sulcus, the narrow gray striae, formed by 
the posterior extremities of the curved lines of the gray substance of 
the cord. 

The posterior roots form ganglions in the intervertebral foramina, 
after which the two roots unite, constituting a spinal nerve ; which, 
escaping through the intervertebral foramen, divides into an anterior 
branch, for the supply of the anterior aspect of the body, and a posterior 
branch, for the posterior aspect. Thus constituted and arranged, the 
substance of the spinal cord is liable to become inflamed, and to develop 
a peculiar train of symptoms, in either an acute or chronic form, both of 
which we will now proceed to consider. 

Symiotoms. — In acute cases considerable pain may be experienced in 
the inflamed portion of the cord, which is liable to be greatly increased 
by motion and pressure, and convulsions or loss of sensation and volun- 
tary motion generally attends, as a consequence of the disease. 

If the superior portion of the cord be inflamed, there is liable to be 
convulsions of the muscles of the head and face, inarticulate speech, loss 
of voice, difficult swallowing, spasmodic breathing, and irregular action 
of the heart. If the inflammation be a little lower, there is constriction 
of the chest, vomiting, pain in the bowels, and a sensation as if a cord 
were drawn round the abdomen. Finally, if the lower portion of the 
cord be the seat of the inflammation, there may be retention or inconti- 
nence of urine, constipation, tenesmus, involuntary stools, &c. 

The voluntary muscles supplied by the inflamed portion of the cord 
may become convulsed or paralyzed, or more frequently they may be 
first convulsed, and then paralytic, and sensation may be either lost or 
retained, according as the anterior or posterior portion of the cord be- 
comes involved in the disease. If, however, both the anterior and pos- 
terior nerves are affected, there is loss of sensation and voluntary mo- 
tion. As the muscles thus lose their power, the organic functions be- 
come impaired or deranged, as of the heart, stomach, liver, kidneys and 
genital organs. Febrile symptoms, according to my observation, are 
seldom developed to any considerable degree, the respiration and pulse 
being slower than in health. 

The duration of the disease varies according to the seat of the inflam- 
mation. If it be in the superior portion of the cord, above the origin of 
the respiratory nerves, the patient may die in two or three days ; but if 
the same amount of disease be situated in the lower part of the spine, 
the patient may survive for a much longer time, as the vital functions 



MYELITIS. 249 

are not so directly interrupted. Acute myelitis may thus pass on and 
become chronic, or the disease may be chronic from the first ; in which 
case the most prominent symptoms are slight uneasiness of the spine, 
and more or less deranged sensations of the limbs, with fatigue attending 
exertion. 

By degrees paralytic symptoms are developed, the patient becomes 
wakeful and tremulous, the limbs become weak, and the gait tottering ; 
the different parts of the body become paralyzed, the surface becomes 
pale, the pulse slow, and the limbs more or less swelled ; and, finally, 
death takes place, the result of a gradual suspension of the voluntary 
and vital functions. 

Anatomical Characters. — Inflammation of the substance of the spinal 
cord may lead to softening, induration or suppuration, as is the case 
with inflammation of the cerebral matter ; but softening is, I believe, by 
far the most frequent result. The softening may consist in only a slight 
diminution of consistence, or it may be complete ; the softened mass 
having either a reddish, yellowish, or nearly natural color ; and it may 
occupy only a portion of the diameter of the cord, or it may involve its 
whole thickness. 

Diagnosis. — Myelitis may be confounded with spinal meningitis, or 
rheumatism of the spinal ligaments or muscles, from both of which dis- 
eases, however, it may be distinguished by the following diagnostic 
symptoms. 

In spinal meningitis the prominent symptoms are severe pain at the 
point of inflammation, extending to the muscles or organs supplied by 
the inflamed part with nerves, and also tonic spasms or convulsions of the 
muscles so supplied, while in myelitis there is less pain in the back or in 
the muscles supplied by nerves from the inflamed portion of the spine, 
and more derangement in the motions, sensations, and functions of the 
muscles and organs, and finally more paralysis, or loss of sensation or 
voluntary motion or both, gradually increasing till there is a total sus- 
pension of the voluntary and vital functions in fatal cases. 

From rheumatism of the spinal ligaments or muscles, myelitis may be 
distinguished by making pressure along the spinous processes, and by the 
side of the spine. If more tenderness is experienced by the side of the 
spine, than along the spinous processes, the disease is rheumatism, or irri- 
tation of the spinal ligaments or muscles ; but if most pain is experi- 
enced from pressure along the spinous processes, the disease is either 
myelitis or spinal meningitis ; and to ascertain which of these affections 
it may be, we have only to take their diagnostic symptoms into account 
and the diagnosis is clear. 

Causes. — Myelitis may be produced by injuries, caries, tubercles, &c, 
but according to my observation, masturbation, venereal excesses, drunk- 
enness, and the use of tobacco, are by far the most frequent causes of 
this most distressing affection. 

I have noticed that cases produced by tobacco are most liable to com- 
mence at or near the lower portion of the cord, while cases produced by 
masturbation, or venereal excesses, may commence in the superior por- 
tion of the cord, perhaps extending from the brain. This, however, 
though it be a general rule, may not be an invariable one. I do not, 



250 DISEASES OF THE NERVOUS SYSTEM. 

however, remember an exception, among the cases which have fallen 
under my observation. 

Pathology. — There is no disease, the nature of which is more clear 
than myelitis, if we keep in mind the structure and functions of the spinal 
cord, and remember the office of the cerebro-spinal and sympathetic 
system of nerves, the former controlling sensations and voluntary mo- 
tions, and the latter presiding over the involuntary or vital functions. 
During the inflammatory stage of the spinal cord, its power of conduct- 
ing influences, both to and from the brain is more or less interrupted, 
both sensory and motor, and hence the derangement of the sensations 
and voluntary motions which occur in the early stage of the disease ; the 
sensory or motor being most affected, according as the anterior or poste- 
rior roots of the nerves become most involved in the disease. 

As the inflammation of the cord passes on to softening, or disorganiza- 
tion, sensation, or voluntary motion, or both, are lost to the part supplied 
with nerves from the diseased portion of the spine ; and as the disease 
progresses, not only sensation and involuntary motion are lost, but by 
degrees the vital functions become interrupted, and though mainly car- 
ried on through the agency of the sympathetic system, their functions 
finally become suspended, and thus the patient dies. 

Prognosis. — Inflammation of the substance of the spinal cord is a very 
dangerous disease, and yet I believe that by a judicious treatment in the 
early stage of the inflammation, it may often be arrested. But if the 
disease passes on to disorganization of the cord, a recovery need not be 
expected. In such cases, however, if the disease be below the origin of 
the respiratory nerves, the disease may assume a chronic form, and the 
patient live on in a wretched state for weeks, months, or even years, 
as happened in one finally fatal case that fell under my care. 

Treatment. — In acute cases of myelitis, if the patient be strong and 
plethoric, and the inflammation active, general bleeding should be re- 
sorted to, after which, blood should be taken by cups from each side of 
the spine, at the diseased point, and a cathartic of calomel or podo- 
phyllin administered. If, however, the disease assumes a chronic form, 
and in all chronic cases, cups, wet or dry, along each side of the diseased 
spine, an occasional cathartic, and finally blistering, pustulation with 
tartar emetic ointment, &c, together with rest, quiet, and a plain diges- 
tible diet, are the remedies upon which we are mainly to depend. In 
very chronic, passive cases, occurring in an?emic patients, from mastur- 
bation, venereal excesses, &c, iron, and strychnine, as tonics for the 
blood and nervous system, I have often found to do well. 

SECTION VII.— CEREBRO-SPINAL MENINGITIS. 

By cerebro-spinal meningitis, I mean a peculiar epidemic, malig- 
nant disease, characterized by inflammation of the meninges of the brain 
and spinal cord, and assuming generally a congestive or typhous char- 
acter. 

This disease more frequently attacks young persons, and especially 
males, and has within the last twenty-five years prevailed extensively in 
different parts of Europe, and especially in France, where it has prevailed 
most extensively in garrisoned towns. In 1848, the disease made its 



CEREBRO-SPINAL MENINGITIS. 251 

appearance in this country, epidemics of it having since prevailed in 
different parts of the United States, till the winter of 1857, at which 
time the disease prevailed extensively in central and western New York, 
but most malignantly in Chemung and Onondaga counties, where the dis- 
ease had a rapidly fatal tendency. During the winter and spring of 
1S5T, a few cases of cerebro-spinal meningitis occurred in this village 
and vicinity, and a few scattering ones since, one fatal case of which fell 
under my care. 

Wherever this disease has prevailed epidemically, the mortality has 
been very great, not less in some cases, than seventy or eighty per cent, 
and in some instances even more than that. It is evident that this dis- 
ease has its origin in a malarious agent of an uncommon degree of 
concentration, either of an animal or vegetable derivation, or what is 
more probable of both, and this appears to have been the opinion of the 
most acute observers, in the localities where the disease has prevailed, 
both in this country and in Europe. The disease appears most frequently 
in low moist localities, and during warm weather in February, March, 
or April, or else in the warm, wet weather which is liable to occur in our 
climate during November and December. 

From the general character of this disease, there would be no impro- 
priety in placing it among the malignant fevers, but as the cerebro-spinal 
meningeal inflammation is its leading characteristic, I have retained the 
consideration of it for this place, the symptoms of which we will now 
proceed to consider. We should, hoAvever, bear in mind what I have 
before explained in relation to the fibrous, vascular and serous membranes 
fo the brain and spinal cord, their relation to each other, and to the cere- 
bro-spinal substance, and also that the membranes of the cord are con- 
tinuous with those of the brain, and identical in structure, except that 
the pia mater of the cord is less vascular and more fibrous than that of 
the brain. 

Symptoms. — In many cases of this disease there is at first, slight dis- 
turbance of the stomach and bowels, with perhaps nausea, vomiting and 
diarrhoea, and soon slight chills and more or less pain in the head and 
along the spine. As the cerebro-spinal pain increases, there is in a few 
hours, restlessness, and an anxious expression of the countenance, deli- 
rium, a cold skin, and often a frequent irregular, and intermittent pulse. 
As the disease progresses, the muscles become spasmodically contracted, 
the head is drawn back, or to one side, and in some cases the whole body 
is rendered stiff or rigid, or in some way distorted, in which condition it 
may remain for days, or even weeks, and finally coma and paralysis 
supervene, and the patient dies, unless a favorable change takes place. 

Such are the ordinary symptoms of a mild form of the disease. But 
in the more severe cases, there is at first a slight feeling of indisposition, 
continuing for an indefinite time, and then there comes a severe chill, or 
congestive stage, with coldness of the surface, irregular pulse, and coma 
more or less profound. The patient sometimes sinks, with perhaps vio- 
lent vomiting and purging, into a state of collapse, very much like that 
of cholera; in which state death may take place in a few hours. 
Or, if reaction becomes established, the pulse is strong, frequent and 
irregular, the skin hot and dry, the thirst urgent, and there is severe 



252 DISEASES OF THE NERVOUS SYSTEM. 

pain in the head and along the spine ; and, finally, there is general 
spasms of the muscles, vomiting of a greenish liquid ; the head is drawn 
backward, or to one side, and there is also delirium, petechia, and great 
restlessness, with excessive irritability, till profound coma and death puts 
an end to the extreme suffering. The tongue, during the early stage of 
the disease, may remain nearly natural, or be covered with a white or 
yellowish fur, but during the latter stages, the tongue may become dry 
and reddish, or be covered with a brownish coat, and instead of diarrhoea 
there is in many cases obstinate constipation from the very first. 

A prominent symptom of this disease are the petechial spots which 
appear on the second day, or later; first upon the face, neck, and breast, 
and then extending gradually over the surface of the body and extremi- 
ties, more or less general. The spots vary in size from the merest speck 
to near half an inch in diameter, and in color from a bright red to a 
purple, or dark brown. In some cases, there are but a few scattering 
scarlet spots, while in others, one-fourth or one-sixth of the whole surface 
may be covered with spots of a dark purple color. This eruption may 
continue till death in fatal cases, but in cases that pass on favorably, it 
gradually fades, till it disappears about the seventh day from the appear- 
ance of the eruption, the ninth day of the disease. It should be remem- 
bered, however, that the eruption is not an invariable symptom in this 
disease. 

The duration of this disease varies from a few hours to two or three 
weeks, the average of fatal cases being probably about nine or ten days. 

Anatomical Characters. — The post-mortem appearances in this disease 
correspond, very nearly, with those presented after death from ^erebral 
and spinal meningitis, the substance of the brain and spinal cord remain- 
ing often in a nearly natural state. 

The meninges of the brain and spinal cord are found more or less 
congested, and generally there is found an effusion of serum, pus, or else 
a layer of yellowish or greenish lymph between the arachnoid and pia 
mater, or else between the pia mater and brain, rather scanty on the 
hemispheres, abundant at the base of the brain, and extending and in- 
vesting the whole length of the spinal cord, and sometimes even giving a 
coat to the roots of the spinal nerves. 

Diagnosis. — Little difficulty need be experienced in distinguishing this 
disease, if we remember the localities, and seasons of the year in which 
it is most liable to occur, the slight premonitory symptoms, the chill, 
congestive stage, or collapse, the violent pain in the head and along the 
spine, the rigidity and spasms of the muscles, more or less general, the 
nausea, vomiting, and either diarrhoea or obstinate constipation ; and, 
finally, the petechia, delirium, coma, &c. 

If all the extrinsic circumstances, the history of the case, together 
with the preceding characteristic symptoms, be taken into, the account, 
as well as the irregular pulse and the strong tendency of the head to be 
drawn backwards, or to one side, I think no one, even though he had 
never seen a case, need be mistaken in forming a diagnosis in this 
disease. 

Cause. — It is probable that the epidemic influence which produces 
cerebro-spinal meningitis is either of an animal or vegetable origin, and 



CEREBROSPINAL MENINGITIS. 253 

very likely both. The rapidly fatal tendency of this disease, in its worst 
form, indicates a concentrated morbid poison as the cause ; and the sea- 
sons of the year, the localities, and the damp, open weather in which it 
makes its appearance, all appear to indicate a concentrated combination 
of koino and idio-miasmata as the cause of this disease. 

It is possible that the paludal poison alone may produce this disease, 
but as it occurs generally in open winter weather, when animal poisons 
are very liable to be generated, and more or less of the paludal, and as 
the symptoms developed are such as might be expected to arise from the 
combined influences of the two causes upon the system, I think we 
have a right to infer, at least, that the two influences combine in pro- 
ducing cerebro-spinal meningitis. It is probable also that a low elec- 
trical state of the atmosphere, which exists during its humid state, when 
this disease makes its appearance, strongly predisposes to the disease, 
and perhaps also favors the cerebro-spinal inflammation, of a passive or 
congestive character, which is the prominent feature of the disease. 

For, if the system part with its only reasonable amount of electricity, 
to restore an equilibrium between itself and a humid atmosphere, vital 
action must be in a measure reduced. If now, while in this reduced state 
of vital power, the combined influence of koino and idio-miasmata be 
be brought to act upon the system, it is not strange that it should strike 
at the very foundation of voluntary and organic life, and a congestion 
or inflammation of the cerebro-spinal membranes be the result. 

Pathology. — Having already intimated my views of the nature of this 
disease, but little further need be said. That a low electrical state of 
the system, caused by a humid condition of the atmosphere, strongly pre- 
disposes the system to this form of disease, in the manner I have sug- 
gested, I have no reasonable doubt. That a morbid animal or vegetable 
poison, or probably both, enters the blood, through the skin, stomach, 
and lungs, I think there can be no reasonable doubt. 

Now, if the animal and vegetable poisons both reach the blood in this 
way, as I believe they do, the animal may be supposed to produce its 
usual effects in materially changing or decomposing the blood, while the 
vegetable only produces a debilitating effect upon the cerebro-spinal and 
nervous system, and thus both leading, the vegetable directly and the 
animal indirectly, to a chill or congestive stage, during which a passive 
inflammation is set up in the cerebro-spinal meninges, and hence the 
symptoms which follow. 

If the predisposition be slight, and the vegetable posion be in excess, 
the blood may be but slightly changed, and then reaction is soon estab- 
lished ; the eruption has a bright red appearance ; the convulsions may 
be slight ; and, with proper remedial measures, the cerebro-spinal men- 
ingeal inflammation may be subdued, and the patient may finally recover. 
But if, on the other hand, the predisposition be strong, and the animal 
poison in excess, the blood may undergo great change, reaction may not 
be established after the chill or congestive stage, passive inflammation, 
with severe congestion of the cerebro-spinal meninges takes place, and 
finally, with vomiting, and perhaps purging, dark petechia, convulsions, 
and coma, the patient passes on to speedy dissolution. Such, I am con- 
vinced, is the true pathology of this most distressing, malignant disease. 



254 DISEASES OF THE NERVOUS SYSTEM. 

Prognosis. — The prognosis in cerebro-spinal meningitis is generally 
unfavorable, but with proper remedial measures, timely applied, many 
cases may recover. 

The unfavorable symptoms are a protracted cold stage, great prostra- 
tion, obstinate vomiting, violent pain in the head and along the spine, 
continuous delirium, obstinate general convulsions, or profound coma, 
and a dark or livid appearance of the eruption. While the favorable 
symptoms are a slight chill, followed by moderate febrile excitement, a 
bright scarlet appearance of the eruption, and an absence of all the un- 
favorable symptoms enumerated above. 

Treatment. — When we take into account the general debilitated con- 
dition of the system in this disease, and remember that the cerebro- 
spinal meningeal inflammation must be of a passive character, produced 
by and kept up in a great degree at least by congestion, the indications 
in the treatment become very plain. At the commencement of the dis- 
ease a full dose of calomel should be administered in castor oil, and the 
oil repeated in six hours if necessary. The feet should be placed in warm 
water, and then sinapisms applied to the bottom of the feet and also over 
the abdomen, or to the epigastrium, and warm sage tea allowed for drink. 

Immediately on the operation of the cathartic, the sulphate of quinine 
shoujd be given in two or three grain doses, with an equal quantity of 
James's powder every four or six hours. The quinine should be con- 
tinued during the continuance of the disease, but two or three grains of 
camphor should be substituted for the antimonial as soon as the febrile 
excitement is subdued. Cups may be applied, wet or dry, in the early 
stage, and later blisters may be of service along the spine, and the 
patient should, be sustained by crust coffee, one-half milk, till such time 
as solid food may be allowed. 

In many cases the operation of the first cathartic will consist of a 
lightish watery substance, containing little or no bile ; the vomiting of a 
greenish watery bilious fluid being continued. In such cases, a grain of 
calomel should be added to each of the powders of quinine and the anti- 
monial, and continued till the vomiting ceases and the alimentary evacu- 
ations become bilious; at which time it may be discontinued. 

Such is the general plan of treatment indicated in ordinary cases of 
cerebro-spinal meningitis, and which, if timely applied, may prove 
effectual, in many cases, at least. But in those decidedly malignant 
cases in which the patient is at once smitten down into a state of collapse, 
with vomiting, purging, and extreme prostration, in addition to the warm 
foot bath, sinapisms to the extremities and epigastrium, warm ginger or 
capsicum tea should be administered internally, with hot brandy sling, 
wine whey, &c, till reaction is established, when the case should be 
treated in all respects according to the plan I have laid down above for 
ordinary cases of the disease. Care should be taken, however, that a 
reasonable amount of proper nourishment be allowed from the very first. 

SECTION VIII.— APOPLEXY. 

By apoplexy, from aztoTaytttiv, to "strike with violence," I mean a 
peculiar disease of the nervous system, characterized by sudden diminu- 



APOPLEXY. 



tion or loss of sensation, voluntary motion, and consciousness; the res- 
piration and circulation continuing; the disease depending on pressure 
upon the brain at some point within the cranium. 

The nervous system, embracing the brain, spinal cord, the cerebro- 
spinal and sympathetic nerves, together generate and distribute an in- 
fluence by which the different functions of the body are performed ; the 
cerebro-spinal system presiding over the voluntary functions, while the 
sympathetic control the involuntary or vital functions. 

The nervous system is also the medium through which mind operates 
upon the physical organization, in a state of health, controlling the 
voluntary functions. 

It is through the brain and nervous system that the mind is enabled 
to control, in a state of health, the voluntary muscles or those parts of 
the system placed under the influence of the will, while the involuntary 
muscles or those that are not subject to the dictates of the will, as the 
heart, have a power of action peculiar to themselves, or are mainly under 
the control of the sympathetic nerves. But the involuntary muscles, 
although they have wisely been placed beyond the control of a depraved 
will, are notwithstanding, dependant upon a healthy action of the cerebro- 
spinal system for the perfect performance of their functions. The cere- 
bro-spinal system may, however, be very mucii deranged, and yet the 
functions of digestion, absorption, nutrition, secretion and circulation, 
which are mainly under the influence of the sympathetic nerves, be car- 
ried on with a comparative degree of regularity. 

Now, if any part of the brain or spinal cord becomes the seat of con- 
gestion, or local disease, to an extent sufficient to arrest the flow of 
nervous influence, the voluntary muscles which are thus deprived of their 
supply of nervous influence are either convulsed or paralyzed, and in 
either case are not subject to the control of the will. If, now, a severe 
pressure be made in the middle of the spine, so as to compress the spinal 
cord to a degree sufficient to arrest the flow of the nervous influence, 
there will be paralysis of the lower limbs. 

If, however, pressure be made only on one side of the cord, the flow 
of nervous influence is arrested only on one side, and paralysis of only 
one limb will be the result. 

The paralysis thus produced may be of motion, or of sensation, or of 
both. If the nervous influence be interrupted only in the anterior roots of 
the spinal nerves, the power of voluntary motion will be lost, but sensation 
will remain ; while if the injury cause only an interruption of the ner- 
vous influence in the posterior roots, sensation will be lost to the para- 
lyzed part, but the power of voluntary motion will remain. If, how- 
ever, the injury cause an interruption of the nervous influence in both 
the anterior and posterior roots of the spinal nerves, we have loss of 
both sensation and voluntary motion. 

Now, let the whole brain become very much congested, and it at 
once stops the flow, and perhaps the generation of nervous influence, so 
that none passes down the spinal cord, and to its own nerves, and there 
is, for the time, a suspension of the power of motion and sensation, in 
all the voluntary muscles of the body, and the involuntary functions, or 
those under the control of the sympathetic nerves, are carried on very 



256 DISEASES OF THE NERVOUS SYSTEM. 

imperfectly. That portion of the system ordinarily under the influence 
of the will, heeds no longer its dictates, and appears to be in a passive 
state ; animal heat being kept up by the continued action of the invol- 
untary muscles, the heart and arteries, though generally in a more or 
less imperfect manner. 

Now this condition, which I have here described, constitutes apoplexy. 
But if the injury of the brain be still greater, so as entirely to suspend 
its functions, the sympathetic nerves have their powers suspended also ; 
and with them the functions of the involuntary muscle, the heart, and 
instead of apoplexy, immediate death is the result. Hence we see that 
there is not a tissue or organ of the body that can continue its functions 
if the flow of nervous influence to the part be cut oif ; and further, that 
the brain is the point whence this influence proceeds, not only to the 
cerebro-spinal, but to the sympathetic nerves. Thus we have the real 
condition in apoplexy, which will account for the symptoms of the dis- 
ease, which we will now proceed to consider. 

Symptoms. — As we have already seen, apoplexy consists of a suspen- 
sion of the voluntary functions, while the involuntary are carried on in 
an irregular or imperfect manner ; the attack coming on, in some cases, 
without any indications of its approach. Generally, however, various 
premonitory symptoms, indicative of cerebral disturbance, precede the 
attack. 

The symptoms which most frequently precede and indicate an apo- 
plectic attack, are deep-seated pain in the head, especially on stooping, 
or turning the head suddenly around ; a turgid state of the veins of the 
head ; throbbing of the temporal arteries ; ringing in the ears ; inability 
to articulate distinctly ; dimness of sight ; obtuseness of hearing ; flashes 
of light before the eyes ; bleeding at the nose ; drowsiness ; confusion 
of ideas; disturbed sleep; loss of memory ; irregular spasmodic contrac- 
tion of the muscles of the face ; and occasionally pains in the pit of the 
stomach, and nausea. Of these symptoms, however, vertigo ; ringing in 
the ears ; dimness of sight ; pain and heaviness in the head, are by far 
the most frequent precursors of this disease. 

Now, it is evident that these symptoms come from a greater or less 
degree of congestion of the cerebral vessels, and as the degree of cere- 
bral congestion differs in different cases, these symptoms may continue 
for a longer or shorter time before an apoplectic attack, or before the 
cephalic congestion produces the apoplectic state. When the cephalic 
congestion or pressure becomes sufficiently strong, whether any pre- 
monitory symptoms have been noticed or not, the patient falls, and sinks 
at once into a state of profound stupor, resembling deep and profound 
sleep, from which it is impossible to arouse him, even in the slightest 
degree. 

If now, as we have seen, the cephalic congestion be very great, and 
the flow of nervous influence suspended, both in the voluntary and in- 
voluntary muscles and organs, the apoplexy terminates in death. If, 
however, only congestion of the cephalic vessels takes place, and the 
vital or involuntary functions continue, and no effusion takes place into 
the brain, as the congestion of the brain is overcome by the circulation 
becoming equalized ; sensation, voluntary motion and consciousness 



APOPLEXY. 257 

again return, and the whole system regains its natural vigor, with only 
a strong predisposition to another attack. 

If however, during the congestion, there is effusion of blood or serum 
into one side of the brain, it frequently so far interrupts the flow of nerv- 
ous influence to one side of the cerebrospinal system, and generally to 
the opposite to that on which the effusion occurs ; that a paralysis of one 
side of the body is the result, either of sensation, or voluntary motion, or 
as generally happens of both. The circulation is kept up in such para- 
lyzed parts by the involuntary, or vital function of the heart ; though in 
consequence of the suspension of sensation and motion in the paralyzed 
part, the circulation is quite languid, and the paralyzed part is, in conse- 
quence, not so warm as the opposite side. 

In other cases, as the patient emerges from the apoplectic state, instead 
of paralysis, there is a high febrile reaction, which will sometimes con- 
tinue for several days, depending no doubt, upon irritation, or inflamma- 
tion of the brain, or its meninges, produced by the severe congestion 
during the apoplectic state ; the local irritation developing a general 
febrile excitement. 

Such are the ordinary symptoms, and terminations of apoplexy; liable, 
of course to variations, like all other affections. 

Diagnosis. — The diagnosis of apoplexy, is not in general, attended with 
much difficulty. When a loss of consciousness of the sensorial function, 
and voluntary motion come on, with a more or less active state of the 
pulse, and full respiration, the case must be regarded as apoplexy. The 
conditions with which apoplexy is most liable to be confounded, are 
syncope, asphyxia, and deep intoxication. 

From syncope and asphyxia, apoplexy may be distinguished by the al- 
most imperceptible pulse, and respiration in these two affections : while 
in apoplexy, the pulse is quite full, and the respiration more or less free. 
It is, however, quite difficult to distinguish apoplexy from intoxication. 
But by a careful observation in reference to the habits of the patient ; 
the smell of his breath; and the general relaxed condition of his muscles, 
a correct diagnosis may be formed in such cases. There is also frequently 
more or less drawing of the mouth to one side in apoplexy, which seldom, 
if ever occurs in intoxication. 

Anatomical Characters. — In some very rare cases, death may occur 
from apoplexy, and yet no well marked lesion of the brain maybe found 
on post-mortem examination ; while in other cases, only marks of conges- 
tion remain. In some cases again, an effusion of serum is found in the 
ventricles of the brain, or else perhaps into the arachnoid cavity ; the 
result, probably, of a sudden extravasation of the fluid, without any 
marked inflammation, or even congestion. 

While other conditions may be found, effusion of blood at some point 
within the cranium, is the most frequent lesion. It may be found between 
the dura mater, and the cranium, between the membranes, in the arach- 
noid cavity, or in the ventricles ; or finally what is more frequent in 
the substance of the brain itself. When blood is found extravasated, it 
may be infiltrated into the cerebral substance ; but it is more frequently 
found in a cavity, which it has formed, varying in quantity from less than 
a teaspoonful, to a half a pint, or more, and occupying any part of the 
17 



258 DISEASES OF THE nervous system. 

cerebrum, or cerebellum ; and generally occupying the side of the brain 
opposite the paralyzed side of the body. 

The effused blood, after a few days, forms a darkish coagulum, which 
gradually becomes of a yellowish appearance, and is finally entirely ab- 
sorbed, leaving a cavity with smooth sides, which, if small, may be found 
in contact, and perhaps connected with small interlacing filaments. 
Blood effused into natural cavities may coagulate, lose its redness, become 
organized, and finally form a false membrane, or else it may become en- 
cysted in a well formed serous sac. 

Prognosis. — Apoplexy is a dangerous disease. If there is a complete 
suspension of the sensorial functions, with great irregularity of the vital 
or involuntary functions, attended with difficult breathing, and an irregu- 
lar intermittent pulse, the vital functions are becoming suspended, and 
the patient will probably die. If, however, there be total suspension of 
the animal or voluntary functions, and still the involuntary, or vital func- 
tions are carried on with a degree of regularity, attended with a 
moderately full pulse, and a regular respiration, the patient may, and 
very likely will recover. 

The duration of an apopletic attack varies from a few minutes to 
several days, by which time it generally terminates in resolution, para- 
lysis, or in febrile excitement. In those cases which terminate in a 
paralysis of one side there is generally an effusion of blood or serum, 
either of which are liable to continue, and so prevent a perfect recovery 
of the affected side. But as the congestion of the engorged vessels of 
the brain is overcome, there may be a sensible improvement, and it is 
possible that the clot of effused blood may be absorbed, and thus a healthy 
action of the affected side be restored. 

Causes. — In relation to the causes of apoplexy, very much depends 
upon the peculiar conformation of the body. For the brain, being 
situated but a little distance from the heart, is supplied, by the carotid 
and vertebral arteries, with about one-sixth of the blood in the system. 

If now a person has a large head and short neck, thus bringing the 
head still nearer the heart, it will constitute a strong predisposition to 
apoplexy. The blood, in such cases, is carried with stronger impulse 
into the cerebral vessels, and a congested state of the arteries of the 
brain, by producing pressure upon the sinuses or large veins, hinders a 
free return of the venous blood, and thus produces congestion of the 
cephalic veins. 

Age, too, constitutes another predisposing cause of apoplexy, as most 
cases occur after the fortieth year. This, however, is not an invariable 
rule. Whatever tends to plethora also predisposes to apoplexy, such as 
a full, nourishing diet, the habitual use of stimulating drinks, and an 
indolent, sedentary course of life. All the preceding causes may pre- 
dispose to apoplexy, by tending to active congestion of the brain ; but 
there are a class of predisposing causes, which, by debilitating, tend to 
produce a passive congestion of the brain, and so predispose to a passive 
form of this disease. 

Now among the depressing causes, the use of tobacco, venereal ex- 
cesses, frequent and long-continued warm bathing, and drunkenness or 
habitual intemperance, are probably the most frequent. Various organic 



APOPLEXY. 259 

affections, such as aneurism of the aorta, hypertrophy of the heart, bron- 
chocele, or other tumors about the neck, increase the liability to apo- 
plexy. Softening of the brain, involving, as it generally does, a more 
or less changed condition of the cerebral vessels, also strongly predis- 
poses to apoplexy, generally of a passive character ; one interesting case 
of which fell under my observation the last season, in a patient not other- 
wise predisposed to apoplexy. 

Distention of the stomach by immoderate eating, the intemperate use 
of spirituous liquors, violent exertion in lifting, or anything capable of 
producing a determination of blood to the head, either active or pas- 
sive, may act as exciting causes of this disease, in those who are natually 
or accidentally predisposed to it. 

Pathology. — Congestion of the brain, either active or passive, is the 
immediate cause of the suspension of sensation and voluntary motion, 
and consequently of all the symptoms which are developed in this disease. 
If, as we have seen, the cerebral congestion be very great, involving to a 
considerable extent the medulla oblongata, respiration may be suspended, 
and death takes place. But if the pressure be less, and the medulla 
oblongata becomes but slightly compressed, respiration and all the vital 
functions may continue, more or less perfectly, and the case terminate, 
either by resolution and restoration to health, or else in bloody or serous 
effusion, leaving a paralysis of one-half of the body. 

Now it is evident that, in each of these cases, congestion of the brain 
is the immediate cause of death when that occurs, of serous or bloody 
effusion when that occurs, with its attendant paralysis ; while in those 
cases in which there is not a suspension of the vital functions, or effusion 
into the brain, a removal of the congestion restores the powers of sensa,- 
tion and motion in the voluntary functions, and health is restored. 

Now this congestion of the brain may be either active or passive, as 
we have already seen. The congestion is active, when in consequence 
of a large head, a short neck, and a powerful heart, together with great 
plethora, the blood is forced with violence into the arteries of the brain, 
producing a congestion, or distention of all their minute ramifications. 
Now by this active congestion of the cephalie arteries, they are neces- 
sarily enlarged, and consequently press upon the cerebral mass, which 
being confined within the bony cavity has little space to expand. In 
consequence of this it probably tends to force the brain to close, more 
completely, the different passages from the cavity of the cranium, and in 
this way impedes the free return or passage of the venous blood from the 
large sinuses, through their constricted passages or channels from the 
cavity of the cranium ; and hence the congestion of the cerebral sub- 
stance is greatly increased. In this way, I am satisfied, does active con- 
gestion produce apoplexy ; very many cases of which have fallen under 
my observation, during the past few years. 

But we have seen that passive congestion of the brain mav cause 
apoplexy, very many cases of which have fallen under my observation, 
and I am inclined to the opinion that a larger proportion of apoplectic 
cases are the result of passive congestion than was formerly supposed. 
It is very common to see the most debilitated patients in malignant 
cholera dying apoplectic in a few hours from the attack, from purely 
ya^ive congestion of the brain. 



260 DISEASES OF THE NERVOUS SYSTEM. 

In cases of great debility, the blood does not circulate freely in the 
extremities, and in consequence more accumulates in the larger vessels 
near the heart, and especially in the vessels of the brain. This produces 
a passive congestion of the brain, and as the brain in debilitated anaemic 
patients can hardly be supposed to have the ordinary powers of endur- 
ance, the flow of nervous influence is perhaps more readily arrested or 
suspended, and thus there is a suspension of the voluntary and perhaps 
vital functions, according to the degree of the passive congestion, and 
consequent interruption of the vital force. 

Thus we see that while apoplexy, probably in most cases, depends upon 
an active congestion of the brain, very many cases depend upon an 
opposite and purely passive congestion, brought about by an ansemic de- 
bilitated condition in the way I have suggested. 

Treatment. — A patient in a fit of apoplexy should be taken immedi- 
ately to a moderately cool apartment, into pure fresh air, and be placed 
with the head considerably elevated ; and have everything removed from 
about the neck capable of preventing the free return of blood from the 
head. If the patient is plethoric and the congestion of the brain is of an 
active character, blood should be drawn from the arm, and afterwards 
cups applied to the back of the neck, and three or four ounces of blood 
taken, and repeated if necessary. This general and local bleeding will, 
in such cases, very much lessen the danger of meningeal inflammation, 
and also tend to lessen the danger of rupture of the cephalic vessels or 
the effusion of blood into the substance of the brain, or of blood or serum 
into the ventricles. 

The feet should then be placed in warm water to lessen the cephalic 
tendency, and also cold applications made to the head, the head being 
kept a little elevated. If the patient can swallow, two drachms of the 
fluid extract of senna may be given with half an ounce of the sulphate of 
magnesia, and the latter repeated every six hours till a free operation is 
secured; or, if there is evidence of bilious derangement, ten or fifteen 
grains of calomel, or two or three grains of podophyllin may be given in 
half an ounce of castor oil, and the oil repeated every six hours till a free 
operation is secured. 

If, however, the patient be unable to swallow readily, a drop or two of 
croton oil may be placed on the back part of the tongue, and repeated 
every two or three hours, and if it does not reach the stomach in suffi- 
cient quantity to operate upon the bowels, a strong infusion of senna 
should be given as an injection, with half a pint of milk and water, and 
perhaps half an ounce each of salt, lard and molasses, and repeated at 
intervals of six hours, till a free operation is secured. 

In cases of apoplexy, depending upon congestion of a passive character, 
general bleeding should not be resorted to. The patient in such a case 
should be placed with the head elevated, and the feet set in warm water, 
and have moderately cool water applied to the head. Dry cups may be 
applied to the temples, and two or three ounces of blood taken by cups 
from the back of the neck, and dry cupping repeated at intervals during 
the continuance of the apoplectic state ; sinapisms too should be applied to 
the feet and lower limbs, and continued as much of the time as the patient 
can bear it, without making sores. 

To assist in equalizing the circulation, the spine should be rubbed 



TARALYSIS. 261 

morning and evening with a strong infusion of capsicum in vinegar. A 
cathartic of calomel or podophyllin should be administered in castor oil 
at first, and later, a pill of aloes given each day to secure a regular 
action of the bowels, and also to lessen the determination of blood to the 
head. Blisters to the back of the neck may be of "very essential service 
after cupping has accomplished what it may do. 

In decidedly anaemic cases in which debility has been the entire cause 
of the attack, in addition to what I have suggested, two or three grains 
of the sulphate of quinine, with or without camphor, may be given every 
six hours, to promote a better circulation and thereby lesssen the cepha- 
lic congestion. In apoplexy from active congestion, toast water with a 
little milk should be allowed ; but in passive cases the patient should be 
sustained with a reasonable amount of nourishing food from the very 
first. All persons that have suffered from one attack of apoplexy, or 
who are in any way predisposed, should observe most rigidly all the laws 
of health, but especially in relation to eating, drinking, exercise, &c. 

SECTION IX.— PARALYSIS. 

Paralysis consists in a loss of sensation, or motion, or both in certain 
parts of the body ; generally embracing one side of the body the lower 
limbs or some particular part, without coma or loss of consciousness. It 
may be the effects of apoplexy, but it may also come on gradually 
without any apoplectic attack. 

Hemiplegia, or that variety which affects one side of the body, is 
generally the effect of an apoplectic stroke, more or less blood or serum 
being effused into the cavities or substance of the brain. It is probable 
also that paraplegia, or paralysis of the lower limbs, may be the result 
of serous or bloody effusion into the cavities or substance of the brain ; 
but generally I think it is the result of injury or pressure in the spinal 
cord, in the dorsal or lumbar region. In local paralysis or that which 
occurs in different parts of the body, of small extent, pressure on the 
nerve or nerves which supply the part, either at their roots or at some 
point before they reach the paralyzed part, is most frequently the cause 
according to my observation. 

Besides hemiplegia, paraplegia and local paralysis, we have a shaking 
palsy consisting in a constant tremulousness, commencing generally with 
the head and upper extremities, and finally extending to the whole body, 
the result generally of either excessive mental labor, intemperance or 
licentiousness in some form, or else of extreme old age. Besides we 
have what has been called rheumatic, hysteric, and lead palsy, but they 
are really only varities of local paralysis, which may conveniently be 
considered with local paralysis produced by other causes ; the mere fact 
of their being produced by rheumatism, hysteria and lead, not neces- 
sarily entitling the conditions to separate names. 

In hemiplegia and paraplegia, the result of serous or bloody effusion 
into the cavities or substance of the brain, there is usually more or less 
mental weakness ; and the same may be true of other forms of palsy, 
but not necessarily. 

Paralysis may be either transient or permanent, depending upon the 



Zb'l DISEASES OF THE NERVOUS SYSTEM. 

causes, or condition upon which it depends. If it depend upon san- 
guineous or serous effusion within the cranium, it will generally remain, 
with little or no permanent improvement. But if it depends upon spinal 
congestion, or irritation, it may frequently be removed, or it may re- 
cover spontaneously. And, finally, if paralysis depend upon a slight 
general softening of the brain, or congestion of the brain, it may in some 
cases be restored, if the imprudence which has led to it can be corrected. 

Paralysis may consist only in a loss of motion or of sensation, or it may 
consist in the loss of sensation and motion, depending upon the nerves 
involved, whether anterior or posterior, or both ; the rationale of which 
I have given in the preceding section. The principal varieties of paraly- 
sis, then, are hemiplegia, affecting one side of the body, paraplegia, 
affecting the lower extremities, and paralysis partiales, or local paralysis, 
involving only parts of a limited extent, including paralysis from rheu- 
matism, hysteria, and lead, as well as all other varieties of local palsy. 

Local paralysis may affect only a particular muscle, or limb, or it may 
involve an entire organ, as the liver, kidneys, or alimentary canal, par- 
tially or entirely suspending their functions. In fact, there is not a 
tissue or organ in the body, but an injury of its nerves may produce a 
paralysis of the part, and thus impair or destroy both sensation and mo- 
tion, and interrupt or suspend the function of the organ or part. With 
these preliminary considerations, let us proceed to consider the different 
varieties of paralysis, and the treatment proper for each 

HEMIPLEGIA. 

Hemiplegia is a paralysis affecting one half of the body, as we have 
already seen ; depending sometimes upon an apoplectic attack, and at 
other times coming on slowly or suddenly, without apoplexy or any other 
very marked symptoms of its approach. 

Symptoms. — Generally, when hemiplegia makes it appearance without 
an apoplectic fit, more or less of the ordinary premonitory symptoms of 
apoplexy precede the paralytic attack, indicating strong sanguineous 
congestion of the cephalic vessels, such as a flushed face, distension of 
the veins of the head and neck, vertigo, a sense of fullness and pain in 
the head, ringing in the ears, drowsiness, impaired articulation of words, 
or loss of speech, confusion of the mind, loss of memory, and a marked 
change of the habitual disposition. In some cases that come on gradu- 
ally, there is slight distortion of the mouth before the hemiplegia super- 
venes, and by careful observation the respiration will be discovered more 
perfect on one side of the chest than the other. 

The involuntary or vital functions are seldom very materially affected 
in hemiplegia ; especially in that which comes on without an apoplectic 
attack at first. If hemiplegia be the result mainly of congestion, it will 
gradually pass off, as the congestion is overcome, and the natural use of 
the affected side will be restored. But if the hemiplegia be the result of 
effusion of blood or serum within the cranium, it will probably be only 
relieved as the congestion is overcome ; and partial or entire paralysis 
of the side will generally continue during life. It is possible, however, 
that in some rare instances, by a marked change in the constitution, the 






PARALYSIS. 263 

clot may be partially removed or changed, so as to allow of a partial or 
entire restoration of the functions of the affected side. 

In those cases of hemiplegia which arise from softening of a portion 
of the brain, there may be a decided improvement in the paralysis, if 
the cause of the morbid change of the brain can be removed before the 
disease has progressed too far. In that variety of paralysis which oc- 
curs in the insane, being in some cases hemiplegia, in others paraplegia, 
and id others still, general ; the result, almost invariably, of softening 
of the gray substance of the brain, with either softening or induration of 
the white matter, together with chronic meningitis ; there is little hope 
of a permanent improvement after the disease has progressed to any 
considerable extent. There is generally hesitancy of speech, a tremulous 
tongue, an unsteady gait in walking, difficulty in voiding urine, and, 
finally, along with paralysis there may be contraction of the muscles, 
especially of the extremities ; involuntary discharges may occur ; respi- 
ration becomes difficult, the heart acts feebly, and the patient dies, hav- 
ing been reduced to idiocy during a distressing illness, which may have 
lasted from a few weeks to several years. 

Treatment. — The treatment of hemiplegia, coming on with apoplexy, 
has already been given with the treatment of apoplexy, but we have yet 
to consider the treatment of hemiplegia not produced by an apoplectic 
fit, and that will also apply to those cases which follow apoplexy. 

During a paralytic shock, the patient should be allowed good air, in a 
moderately cool apartment, and have the head well elevated and kept 
cool, and the feet placed in warm water. If the patient is plethoric, or 
of a sthenic constitution, blood should be drawn from the arm, and after- 
wards a few ounces of blood taken from the back of the neck by cups. 
If, however, the patient be feeble, blood should only be taken by cups ; 
and in very debilitated cases, only dry cups should be applied. 

A cathartic of calomel or podophyliin should be administered at first, 
and the bowels kept moderately loose in plethoric patients, by the neu- 
tral salts, but in feeble patients, by a pill of aloes, taken at evening each 
day. To lessen the cephalic tendency, and promote perspiration, the 
James's powder may be given, in three or four grain doses, every six 
hours, for the first few days. 

Dry cups, blisters, or pustulations, with tartar emetic ointment, 
should be kept up to the back of the neck, during the first few days or 
weeks, if it continue so long. If, however, after continuing this treat- 
ment for a reasonable time, the condition of the paralyzed side con- 
tinues stationary, we have a right to infer that it is the result of effusion 
within the cranium ; further medical treatment should be abandoned, 
and the case left to the efforts of nature, the patient being directed to 
observe most rigidly, the laws of health, and especially to avoid all those 
causes which tend to produce cephalic congestion. 

In the paralysis occurring with insanity, whether it be hemiplegia, 
paraplegia or general, the cause of the disease should be sought out and 
removed, if possible, and then the case treated on general principles, 
while any grounds of hope remain in the case. Generally in such 
cases, gentle cathartics, or laxatives, a regulated diet, tonics of iron, 
and perhaps strychnine, good air and quiet, together with blisters back 



264 DISEASES OF THE NERVOUS SYSTEM. 

of the ears, or to the back of the neck, constitute our main reliance. 
If this treatment be resorted to early, a recovery is possible ; but if the 
case has progressed to any considerable extent, the patient will ulti- 
mately die, in most cases at least. 

PARAPLEGIA. 

By paraplegia, I mean paralysis affecting the lower limbs, and lower 
part of the body. Paraplegia may sometimes be the result of an affec- 
tion of the brain, as of softening, or effusion of blood or serum, but 
generally it arises from some injury, irritation or congestion of the spine, 
or else from effusion of blood or serum at some point along the dorsal or 
lumbar portion of the spine. 

Symptoms. — Paraplegia generally comes on gradually, unless it be 
the result of direct mechanical compression of the spinal cord. At first 
the patient, after having suffered from slight uneasiness of the back for 
a time, feels an awkwardness in the motion of the lower extremities. 
Early this is slight, and experienced mostly on first rising to walk, or 
when the patient becomes very much fatigued. This awkwardness, how- 
ever, increases, till the patient is unable to walk without the aid of a cane. 

As the disease advances, the bladder becomes more or less paralyzed, 
so that the urine is expelled with difficulty, the stream becoming more 
and more feeble, till at length it dribbles away involuntarily. The 
bowels, too, are more or less paralyzed, and consequently very much 
constipated, frequently being entirely inactive, without the use of a 
stimulating cathartic or injection. If now, in such a case, the kidneys 
become paralyzed, as happened in one case that fell under my observa- 
tion, the secretion of urine is suspended, and the patient very soon dies. 

In paraplegia, the power of motion in the lower part of the body and 
limbs may be lost, and the sensation remain nearly natural. In other 
cases, however, sensation and motion are both lost at the same time, or 
the one first, and then gradually the other. 

Causes. — The causes of paraplegia are various. In those cases that 
depend upon cephalic derangement, such as congestion of the brain, the 
effusion of blood or serum, or softening of the brain, if it is not the 
effects of an apoplectic stroke, it is brought on by the same causes which 
produce apoplexy; the immediate cause of the paraplegia being pressure 
upon some portion of the brain, or a morbid change of its structure, such 
as softening, induration, &c. 

Any direct mechanical injury of the spinal cord, by which its sub- 
stance becomes congested, or compressed, may produce paraplegia; such 
as blows, fracturing or depressing the spinous processes of the vertebrae, 
&c. Or an injury of the spine may, by producing irritation of the cord, 
cause so much congestion of its blood vessels, as to interrupt the flow of 
nervous influence, and thus produce paraplegia. An inflammation of the 
spinal cord, or its meninges, may terminate in softening of its substance, 
or in effusion of serum, &c, into the arachnoid cavity, or elsewhere, 
which may produce paraplegia, by interrupting the flow of the nervous 
influence. 

Again, a poisonous agent, as tobacco, may, by debilitating the brain 
and nervous system, so far impair the functions of the brain, that there 



PARALYSIS. 265 

will not be a sufficient amount of nervous influence generated in the 
brain to supply the nervous system, and what is generated will not re- 
ceive sufficient vital force to be sent to the lower extremities, and conse- 
quently paraplegia will be the result. 

Many cases of this character have fallen under my observation during 
the past few years. Dr. Harvey Jewett, an eminent physician of Canan- 
daigua, in this State, has also noticed, it appears, the debilitating effects 
of tobacco upon the lower portion of the spinal cord, several interesting 
cases of which he has reported in the Buffalo Medical Journal, for May, 
1853.* 

In one marked case of this character that fell under my observation 
during the summer of 1853, there was at first weakness and tremor of 
the lower limbs, then paralysis of the bladder and lower portion of the 
alimentary canal, and finally of the kidneys, and on the suspension of 
their functions the patient died, evidently the result of the excessive and 
protracted use of tobacco. 

Masturbation or venereal excesses may produce paraplegia in very 
nearly the same manner as tobacco, by impairing the vital functions of 
the brain, and also impairing the ability of the brain to produce a proper 
distribution of the nervous influence to remote parts, and especially to 
the lower extremities, in consequence of which paraplegia is the result. 
These causes may also produce paraplegia, in part at least, by the local 
irritation which is set up, and perhaps softening at the origin of the 
spermatic nerves, near the junction of the dorsal and lumbar regions of 
the spine. 

I am satisfied that tobacco, licentiousness, and drunkenness, with 
various other excesses and abuses of the system, are the most frequent 
causes of that peculiar tremulous condition, either partial or general, 
which has been called shaking palsy. It may, however, occur from age, 
and general debility, from various depressing agents, accidentally 
brought to bear upon the system. In conclusion then, I am compelled 
to believe, from careful observation, that paraplegia occurs most fre- 
quently in children, and young persons from masturbation ; in middle 
aged persons from venereal excesses, onanism and various other abuses, 
while in advanced life, it is frequently the result of tobacco, and perhaps 
in some cases of intoxicating liquors. 

Prognosis. — The prognosis in all those cases of paraplegia which 
arise from congestion and irritation only of the spinal cord, may be re- 
garded as favorable, while all those cases which are the result of san- 
guineous or serous effusion, either into the brain or along the spinal 
cord, may be regarded as unfavorable. 

In those cases of paraplegia produced by masturbation, sexual excesses, 
tobacco, drunkenness, and other abuses of the system, the prognosis is 
generally unfavorable ; but cases may recover, if the cause can be re- 
moved at an early stage of the disease, and the patient can be induced 
to conform strictly to the laws of health. 

Treatment. — In those cases of paraplegia, depending upon a cephalic 
cause, the same treatment is proper that I have suggested in the treat- 
ment of hemiplegia, and it will generally be applied with only a partial 

* See Buffalo Medical Journal, Vol. 8. No. xii., p. 721. 



266 DISEASES OF THE NERVOUS SYSTEM. 

relief to the patient. Sometimes, however, a more favorable result fol- 
lows. In those cases too, which depend upon the continued use of 
tobacco, and other abuses of the system, and especially sexual abuse, 
nothing very favorable can generally be accomplished, except to remove 
the cause. In some cases, however, of this kind, in young patients, by 
enjoining the most strict and rigid observance of the laws of health, and 
pursuing a tonic course of treatment, the patient will sometimes recover, 
after some of the most unpromising symptoms have occurred. 

Such cases are generally attended with great debility, both of the 
blood and nervous, or cerebro-spinal system. Iron, and generally the 
citrate, in small doses, continued for a long time, will do all for the blood 
that can be reasonably expected in such cases. As a tonic for the 
cerebro-spinal and nervous system, strychnia in small doses, continued for 
some time, will generally do well. A grain of the muriate of strychnia 
may be dissolved in six or eight ounces of water, and a teaspoonful given 
three times per day, before each meal, and continued for a long time, in 
cases in which there is no marked local irritation of the brain or spinal 
cord. 

In those cases of paraplegia, depending upon irritation, with more or 
less congestion of the spine, in the dorsal, or lumbar region ; cups at first, 
wet or dry, on each side of the spine, and then blisters, or pustulation, 
with tartar emetic ointment, continued for a reasonable time, will some- 
times remove the disease ; one terrible case of which, I succeeded in 
removing, after nearly the whole system had become partially paralyzed. 
In this case, the child had a fall on the door-sill, which injured the middle 
portion of the spine, and produced a passive inflammation, which extend- 
ing to the brain, so far interrupted its function, as to produce decided 
idiotic symptoms. 

After having remained in this deplorable state for about twelve months, 
with the whole body partially paralyzed, this apparently hopeless case 
was cured by blistering, successively, the whole length of the spine, by a 
little at a time, and giving for several months, the citrate of iron in two 
grain doses, three times per day, after each meal. I succeeded in regu- 
lating the bowels in this case, with a solution consisting of rhubarb, and 
the sulphate of magnesia, of each four drachms, in eight ounces of water ; 
a teaspoonful of which was given every morning, till the constipation was 
overcome. Thus in cases of this kind, by the aid of cups, blisters, tonics, 
and laxatives, success may attend in apparently hopeless cases. 

In cases of paraplegia depending upon effusion into the arachnoid 
cavity of the spine, I believe there is no great certainty of relief from 
medical treatment ; one fatal case of which fell under my care a few 
years since, terminating probably in softening of the cord itself. The 
only reasonable hope of relief in such cases, is from the long continued 
use of the iodide of potassium, internally, and the application of blisters 
at first along each side of the spine, and then the continued application 
to the spine of iodine ointment, with a hope of effecting absorption of the 
effused fluid, which may possibly sometimes be accomplished in this way. 

In that peculiar tremulous condition of the system, which has been 
called shaking palsy, the cause should be sought out, and, if possible re- 
moved, and then by a prudent observance of the laws of health, proper 



PARALYSIS. 267 

exercise, and tonics for the blood and nervous system, such as iron, 
strychnia, &c, an improvement may follow in some cases ; but this is 
by no means certain. Such then are the principles which are to guide 
us in the treatment of paraplegia, which having considered, let us proceed 
to the consideration of partial paralysis. 

PARALYSIS PARTIALIS. 

By partial or local paralysis, I mean that variety in which the morbid 
condition extends only to a limited extent. It may be of sensation, or 
motion, or both ; and it may involve a single muscle, a whole limb, or 
any organ of the body. When it involves a whole limb, as a leg or arm, 
it generally depends upon an irritation, congestion, or some other morbid 
condition of the corresponding side of the spine, at the point where the 
nerves come off to supply the limb. 

If the paralysis extend only to a particular muscle, or set of muscles, 
as of the face, it is generally from pressure on a nerve at some point 
away from the brain or spine ; often in its passage through a foramen in 
a bone, by which the flow of nervous influence is interrupted, and a 
partial, or local paralysis is produced. The most frequent seat of local, or 
partial paralysis, involving only a small part of the body, is that which 
effects one limb, one arm, or one side of the face ; but no tissue or organ 
of the body, is exempt from this variety of paralysis. 

Causes. — The immediate cause of paralysis of a lower limb is gene- 
rally, as we have seen, pressure on the corresponding side of the spine, 
or spinal nerves, in the lumbar or sacral region. The cause of paralysis 
of one arm is pressure on the corresponding side of the spine at the point 
between the shoulders, where the brachial plexus of nerves are given off. 
While paralysis of the muscles of one side of the face, generally depends 
upon pressure on the facial nerve, in its passage through the stylo- 
mastoid foramen, as it emerges to be distributed to the muscles of the 
face. 

As to the remote causes, the same operate, both of a local and gene- 
ral character, that I have mentioned as producing paraplegia ; such as 
injuries, with serous or other effusions along the spinal cord, or soften- 
ing from inflammation, &c. Rheumatism, hysteria, and some other dis- 
eases, occasionally appear to act as causes of local paralysis, or at least 
are attended with paralysis; generally, however, of a transient cha- 
racter. Local paralysis occurring in rheumatism, or in rheumatic condi- 
tions, probably depends upon thickening of the nervous sheaths, if it be 
of only a limited extent; but when paraplegia occurs in such cases, it 
depends upon congestion of the spinal cord, or else thickening of its 
meninges, passing on to an extent sufficient to produce paralysis. 

In cases of local paralysis, caused by hysteria, or occurring in hysteric 
patients, there is generally diminished sensibility, with temporary loss of 
voluntary motion, depending, I am inclined to believe, in part upon 
cerebro-spinal congestion, and also perhaps in part upon a bad distribu- 
tion of the nervous influence, which is apt to be a prevailing tendency in 
hysteric conditions. Finally, it is probable that lead, in its various forms, 
is a very frequent cause of local paralysis ; affecting generally, at first, 
the extensor muscles of the hands, and perhaps extending more or less 



268 DISEASES OF THE NERVOUS SYSTEM. 

to all the muscles, which become flabby, the whole surface often present- 
ing a pale leaden hue. 

In some cases, however, I have known lead to produce paraplegia, and 
in other cases still paralysis of one limb ; in every case falling under my 
observation, being attended with neuralgic pains, of a more or less 
tedious character, either in the affected limb or in other parts of the 
body. The lead probably acts in such cases not only upon the brain 
and spinal cord, but also upon the tissues of the muscle, or muscles, in- 
volved in the paralysis. 

Treatment. — In the treatment of partial or local paralysis, cups, 
blisters, and other counter-irritants, over the seat of the local irritation 
or congestion, may be indicated, to take off the pressure on the nerve or 
nerves involved. After the local irritation or congestion is subdued, and 
the undue pressure on the nerves removed, if the paralysis continue, the 
muriate of strychnia should be given in moderate doses till the paralyzed 
part is restored. 

In local or general paralysis, depending upon lead, I have generally 
succeeded with the iodide of potassium, in five grain doses three times 
per day, continued for several weeks, and the application of iodine oint- 
ment over the seat of local irritation, if any exist, along the course of the 
spine. 

SECTION X.— EPILEPSY. 

By epilepsy, from the Greek Erf&apj3ave, "I seize upon," I mean a dis- 
ease of the nervous system, manifested by convulsions, recurring at irre- 
gular periods in paroxysms, accompanied by a temporary loss of con- 
sciousness, sense, and voluntary motion, and usually terminating in 
somnolency. 

The brain appears to be the special seat of epilepsy, and it may be 
either organic or functional, or symptomatic of irritation or derange- 
ment in other parts, as of the stomach, bowels, genital organs, &c, but 
the whole nervous system is always more or less involved in this disease. 

Symptoms. — The epileptic attack may come on suddenly, without any 
symptoms of its approach. Generally, however, certain symptoms pre- 
cede the occurrence of the paroxysm, such as a disturbed or distressed 
feeling in the head, confused state of the mind, giddiness, dimness of 
sight, ringing in the ears, flashes of light before the eyes, distention of 
the veins of the neck, an anxious feeling in the precordial region, start- 
ing during sleep, loss of distinct articulation, temporary deafness and 
drowsiness. 

Just before an attack, some patients are gloomy or peevish, while 
others are exceedingly lively and cheerful ; depending, no doubt, upon 
the effects which a rush of blood to the head produces in different indi- 
viduals. For, whatever may be the remote cause of epilepsy, the imme- 
diate cause of the epileptic fit is a rush of blood to the brain; which, 
suspending the generation of nervous influence, or interrupting its dis- 
tribution, produces, doubtless, the peculiar sensation which many epilep- 
tics experience, of cool air upon the body, beginning often in the lower 
limbs and passing to the head, as the flow of nervous influence is gradu- 
ally withdrawn or withheld. 



EPILEPSY. 269 

After the premonitory symptoms have continued for an indefinite time, 
when they occur, Tvith or without the sensation referred to above, the 
aura epileptica, the epileptic seizure occurs: when, if the patient be sit- 
ting or standing, he suddenly falls down in a state of insensibility, and 
immediately becomes convulsed more or less violently. In many instances 
the convulsive action of the muscles, especially of the face, are frightfully 
violent. The whole frame, too, is frightfully agitated; the eyes roll 
about, the lips and eyelids are convulsed, the tongue is spasmodically 
thrust from the mouth, which, with the foaming of the mouth, gives the 
countenance a very wild appearance. 

In some instances the teeth are firmly pressed together, at other times 
the jaws are widely distended; the thumbs are generally firmly pressed 
in upon the palms of the hands, but this is not invariably the case. The 
spasms are generally of the clonic kind, but sometimes the muscles re- 
main for a time rigidly contracted, the body being bent either backward 
or to one side, as in tetanus. The face is occasionally pale, but gene- 
rally livid, with a turgid state of the veins of the neck. The heart 
usually palpitates tumultously ; the pulse is irregular, contracted and 
weak, and the respiration difficult and in violent cases sonorous. 

After an indefinite period, varying generally from five to thirty 
minutes, either suddenly or gradually, these spasmodic symptoms abate; 
the respiration becomes full, and more regular; the countenance more 
composed, and the patient finally falls into a state of stupor or deep 
sleep, out of which he wakes with a feeling of languor, confusion and 
torpor of mind, which state may continue declining for several hours, and 
in some cases for even days. The countenance generally exhibits a more 
or less vacant or stupid expression, and the eyes are apt to be dull and 
wandering. During the somnolent state, the patient generally perspires 
freely, especially about the head, neck, and breast; sometimes, however, 
the perspiration is confined to one side. 

In mild cases of epilepsy the attack comes on suddenly, and after a 
few minutes of partial convulsions of the muscles of the face and neck, is 
quickly subdued, and the patient becomes conscious. The average dura- 
tion of an epileptic paroxysm is probably about fifteen minutes, but it 
may continue for several hours. Usually but one fit occurs at a time, 
but occasionally several succeed each other in rapid succession, with only 
short intervals between; a remarkable instance of which fell under my 
observation a few years since. 

The interval between the paroxysms varies from a few hours to several 
days, weeks or even months, generally growing more frequent the longer 
the disease has continued. In some cases the paroxysms occur with 
great regularity for a long time, and this, I believe, is most apt to be the 
case in females, if there is suppression of the mensis. In such cases, I 
have known the paroxysms to occur once in four weeks, or thereabouts, 
for a great length of time. In most cases, however, the paroxysms 
come on at irregular intervals, varying from a few days to several weeks, 
depending, in some degree, upon the state of the atmosphere, and very 
much upon the accidental occupation of the patient, and the degree of 
physical and mental excitement. 

In some rare instances, epilepsy terminates spontaneously, but gene- 



270 DISEASES OF THE NERVOUS SYSTEM. 

rally the fits continue to occur more frequently during the life of the 
patient, or it may terminate in apoplexy and death, as happened in one 
case under my care about two years since. 

In those cases that commence early in life, and continue for many 
years, there is often more or less mental weakness exhibited, approach- 
ing sometimes to idiocy, several marked cases of which have fallen under 
my observation, one of which is under my care at the present time. 

It has been thought by some that in those cases in which idiotic symp- 
toms make their appearance, there is no hope of improvement or perma- 
nent recovery ; but this is not invariably the case, for in one patient in 
which the disease commenced in early childhood, and continued on to 
the twelfth year, with a decidedly idiotic expression of the countenance, 
I succeeded in entirely arresting the disease, and the boy, now grown to 
be a man, is smart, bright and intelligent, and enjoying good health. 
Generally, however, in those cases which exhibit much mental weakness, 
the prospect of recovery, or even permanent improvement, I believe is 
very slight. 

It should be remembered, however, that while the tendency of epilepsy 
is generally towards imbecility, that it is apparently not invariably so ; 
some patients passing on even to advanced age without any material ap- 
parent impairment of the mental faculties, as was the case with Caesar, 
Mahomet, and Napoleon, and as has been noticed in other epileptics of 
less distinction. 

Anatomical Characters. — On the examination of the brain of those who 
have died of epilepsy, during a paroxysm, the brain and its meninges 
are found greatly congested, the cineritious substance being of a deep 
red, and the white substance of a more or less reddish appearance. 

This appearance, however, is probably the result of the recent conges- 
tion, as there is generally no morbid lesion indicative of permanent dis- 
ease anterior to the fatal congestion. This is not always true, however, 
in very protracted cases, in which there has been marked mental weak- 
ness, paralytic symptoms, &c. In these cases there may be found marks 
of meningeal inflammation, more or less induration or softening of the 
cerebrum and cerebellum, a general injection of the cerebral vessels, 
thickening and adhesion of the membranes to the substance of the brain, 
and more or less effusion, of blood or serum, into the arachnoid cavity, 
or into the ventricles of the brain ; the result, probably, rather than the 
cause of the protracted epileptic disease. 

The cerebellum is often found in epileptics of a softer consistence than 
in health, and there is frequently some thickening or internal projection 
of the cranium, the result of external violence, which has evidently pro- 
duced the disease ; one interesting case of which I saw in Philadelphia, 
during the winter of 1845. This patient had received an injury, some 
years previous, which had depressed the skull, I believe near the lambdoidal 
suture, a little upon one side of the head ; the symptoms following the de- 
pression not being very great, the bone was not disturbed, and the patient 
became epileptic, the paroxysms occurring quite regularly once in about 
three weeks. Professor Mutter removed the depressed portion of the 
bone, and there was, I believe, no return of the epileptic paroxyms. 
It is probable that tubercles, abscesses, and thickening of the mem- 



EPILEPSY. 271 

branes of tbe brain, which are sometimes found in epileptics, may have 
preceded, and in some cases produced, the epileptic disease. 

Causes. — There appears to be a hereditary predisposition to epilepsy 
in some individuals and families, but in what that predisposition consists, 
is not quite certain. But as the iminediatecause of the epileptic paroxysm 
is pressure of blood upon the brain, and apparently more especially of 
the cerebellum, it appears to me quite possible that among the predis- 
posing physical conditions, a preternatural development of the vertebral 
arteries, by which they convey an undue amount of blood to the cere- 
bellum, is one of not the least importance. 

Hereditary peculiarity of organization, by which the tissues, and espe- 
cially the brain, are rendered more soft, and consequently more suscep- 
tible to slight impressions, and especially to a congested state of the 
cephalic vessels, may predispose to epilepsy. This appears the more 
probable, when we remember that children are more liable to epilepsy 
than adults, in whom the brain has acquired more firmness and power of 
endurance. It appears that more cases of epilepsy occur at or before 
puberty than subsequently to that period. And it is probable that the 
nervous irritability and cephalic tendency, which occurs in many at 
about the age of puberty, may at least strongly predispose to epilepsy, 
if it does not act as an exciting cause of the disease. 

It is probable that the habit of masturbation so common in both sexes 
about that age, does much to render irritable the nervous system, and to 
change more or less the substance of the brain itself, and thus acts as a 
strong predisposing or exciting cause of epilepsy. 

Irregular eating, which is so common a habit with children, by pro- 
ducing dyspepsia and gastro-enteritis, and affecting the brain sympa- 
thetically, very often acts as a cause of epilepsy in those who are, or are 
not, hereditarily predisposed. In one case of epilepsy, in Jefferson 
county, N. Y., beginning in a child at about three years of age and 
continuing to the twelfth year, going on constantly from bad to worse, 
so that at last he averaged about three fits per night, I succeeded in 
permanently arresting the disease with very mild measures, after I had 
corrected his habit of irregular eating. 

In this case the boy from early childhood had been in the habit of 
taking food at all hours of the day, and eating but very little at meal 
time ; which habit had so far impaired his digestion, and produced and 
kept up gastric irritation, affecting the brain sympathetically, that it had 
not only produced, but kept up the epileptic paroxysms ; and no 
measures had any influence in arresting the disease, till this habit of 
irregular eating was corrected. 

Another case, a girl twelve years old, residing in Madison county of 
this state, fell under my care about four years since ; in which irregular 
eating was probably the cause of the disease. In this case I corrected 
this habit of irregular eating ; and with very mild measures succeeded in 
effecting a cure in about twelve months, though she took tonics for about 
six months after the epileptic paroxysms were arrested. Other cases of 
epilepsy have fallen under my observation, in which I am confident that 
irregular eating had been either the predisposing or exciting cause of 
the disease ; one of w r hich, of an epileptic character, I now distinctly 
remember from the state of Michigan. 



Zrl DISEASES OF THE NERVOUS SYSTEM. 

Among the exciting causes of epilepsy, some act directly upon the 
brain, while others act on distant parts, as the stomach, bowels, liver, 
kidneys, genital organs, &c, the impression being conducted to the brain 
through the medium of the nerves. The causes which act directly upon 
the brain, are, as we have seen, depression of some portion of the bones 
of the cranium ; thickening or tubercles of the membranes of the brain, 
tumors or some morbid change in the cerebral substance, and bloody or 
serous effusion into the ventricles of the brain. The disease is said to 
have been produced directly by seeing patients in the epileptic paroxysms, 
and also by persons feigning the disease. 

Among the exciting causes of epilepsy, which affect the brain sympa- 
thetically, are indigestion, intestinal worms, suppression of the menses, 
the repulsion or sudden drying up of eruptions on the scalp, the 
habitual use of tobacco and intoxicating liquors, irritation from biliary 
and urinary calculi, atmospheric vicissitudes ; and in fact any cause 
capable of producing irritability of the nervous system, and a determi- 
nation of blood to the brain, and especially to the cerebellum, may be 
either direct or indirect causes of epilepsy. 

Pathology.— 1 am satisfied that epilepsy consists in a morbid excita- 
bility of the whole nervous system, including, of course, the brain ; and 
that each paroxysm consists in an increased excitement, or irritation of 
the whole nervous system, but especially of the brain itself, in conse- 
quence of which it becomes congested, and hence all the symptoms of 
the disease are developed. The cause of this morbid excitability of the 
nervous system may be, as we have seen, in the brain, or it may be in 
some remote part ; only a slight increase of the excitability to an irrita- 
tion being sufficient, in either case, to produce enough cephalic conges- 
tion to bring on a paroxysm, more or less violent. 

Immediately before the epileptic attack there is vascular turgessence 
of the brain, including the cerebellum, but not sufficient to produce apo- 
plexy ; hence we have a suspension of the mental functions, as sensation, 
perception, consciousness, &c, while the motor functions are deranged, 
but not abolished, as is the case in apoplexy. Thus it is probable that 
we may have epilepsy without any organic derangement of the brain, its 
functions only being deranged by the irritation and congestion alone, 
caused, as we have seen, by a general irritable condition of the whole 
nervous system, produced by causes acting upon parts remote from the 
brain. 

But while epilepsy may be produced in this way, it should be remem- 
bered that organic disease of the brain, or its meninges, such as inflam- 
mation, tumors, thickened membranes, exostosis, depressed bone, serous 
or bloody effusion, &c, may produce sufficient derangement, in the cor- 
tical substance, to suspend the mental functions, and also sufficient in 
the white to derange the motor function, and thus epilepsy may be pro- 
duced by organic disease of the brain or its meninges. 

Now that epilepsy should be paroxysmal is not strange, whether it be 
produced by organic or functional disease of the brain, for nearly or 
quite the same degree of excitability of the brain may exist in either 
case ; only requiring this excitability to be increased to irritation, by 
some exciting cause, to bring on sufficient congestion to develop a 
paroxysm. Slight accidental causes may develop a paroxysm, if the 



EPILEPSY. 2T3 

morbid excitability of the brain be considerable ; but if the morbid 
excitability of the brain be slight, a more considerable exciting cause is 
required, and so the paroxysms are liable to occur less frequently. 

Thus it is that the paroxysms come on so irregularly, except in cases 
in which the exciting causes occur at regular periods, as is the case in 
females laboring under menstrual irregularities, the paroxysms coming 
on, in such cases, according to my observation, when there is an effort 
in the system to bring on the menstrual discharge, when, failing in this, 
the brain becomes irritated and congested, and an epileptic paroxysm is 
the result. Thus we have, in my opinion, the true pathology of this per- 
plexing, and most distressing paroxysmal disease ; all the symptoms and 
peculiarities of which may thus be accounted for. 

Diagnosis. — Epilepsy may be distinguished from apoplexy, hysteria, 
and various accidental convulsons. by the following differences. In epi- 
lepsy the muscles of the face are contracted, as well as those of other 
parts of the body, while in apoplexy the muscles are relaxed and motion- 
less. During the latter stage of an epileptic fit, when coma has super- 
vened, the face is pale, the pulse is feeble, and there is foaming at the 
mouth ; while in apoplexy the face may be flushed, the pulse full and 
strong, and, in addition, there is generally stertorous breathing, which 
is not the case in epilepsy. 

In hysteria the face is not so much distorted, there is not the foaming 
at the mouth, and the fit does not terminate in a heavy sleep, as is the 
case in epilepsy. In hysteria, too, there is more generally involuntary 
laughing or weeping, and, generally, a continuation of some degree of 
consciousness, which is not the case in genuine epilepsy. 

In accidental convulsions, occurring from dentition, intestinal irrita- 
tion, from the puerperal state, &c, there is less frothing at the mouth, 
less stertorous breathing, and a more sudden return of mental activity, 
after the cessation of the convulsions, than is the case in epilepsy. 

Feigned cases differ from the real disease, in every essential particular ; 
so that in order to detect feigned cases, it is only necessary to notice all 
the symptoms which are developed, and to take into account all the ex- 
trinsic circumstances, to avoid deception, and imposition in such cases. 

Prognosis. — The prognosis is unfavorable in all those cases in which 
there is organic disease of the brain, or its investing membranes, or 
bones ; at least so far as a permanent recovery is concerned. But in 
those cases of epilepsy, in which the cause of the general nervous excita- 
bility is in some part of the system remote from the brain, the brain 
being irritated sympathetically, there may be reasonable hope of a per- 
manent recovery, if the imprudence which has produced this irritable 
condition can be removed, or corrected, and the patient subjected to a 
judicious treatment. 

It has been supposed by some, that those cases of epilepsy which occur 
in early childhood, are necessarily exceedingly obstinate, and seldom if 
ever yield to remedial measures ; but such has not been the result of my 
observation in epileptics ; the only cases permanently cured, occurring 
in my practice, having been under fifteen years of age. As a general 
rule, the prognosis is rendered more unfavorable the longer the disease 

18 



274 DISEASES OF THE NERVOUS SYSTEM. 

has continued, and especially if decided paralytic, or idiotic symptoms 
have supervened. 

Treatment. — During an epileptic paroxysm, the patient should he 
placed upon a hed, with the head a little elevated, and all reasonable 
measures taken to prevent the patient from injuring himself, and others, 
till the paroxysm passes off. If apoplectic symptoms occur, blood should 
be drawn from the arm, or taken by cups from the temples, or back of 
the neck, and cold applications made to the head, with sinapisms to the 
extremities, warm foot baths, &c. 

In very debilitated patients, if the pulse become feeble during the 
paroxysm, and there appears to be danger from apncea, ammonia, or 
camphor should be held near the nostrils, sinapisms applied to the ex- 
tremities, and the whole length of the spine rubbed with a strong infusion 
of capsicum in vinegar, applied a little warm. While then it is possible 
that circumstances may occur, during the paroxysm of epilepsy, render- 
ing some such interference as I have suggested necessary ; it should be 
remembered that symptoms very rarely arise, which render any interfer- 
ence necessary, except to prevent the patient from injuring himself and 
others. 

The indications in the treatment during the intervals, for the purpose 
of permanently eradicating the epileptic disease, are generally very plain 
if the real condition of the patient can be ascertained, and also the cause, 
or causes which have been operating to produce it. In all those cases in 
which the primary irritation is about the brain, either intrusion of bone 
upon the brain, thickening, or tubercles of its meninges, or some morbid 
change of the brain itself, or effusion into its ventricles ; the exact con- 
dition should be ascertained as near as may be, and also the causes which 
have led to it. 

The cause in every case, which may have been operating to produce 
the cephalic irritation should be removed, whether it be the result of an 
accident, as depression of bone, or of imprudence of any kind, such as 
the use of tobacco, intoxicating liquors, masturbation, excessive venery, 
&c, which have produced a morbid change in the brain, without necessari- 
ly having first produced local disease in other parts of the system. 

If the epilepsy has been produced by depression of a portion of bone, 
it should be removed with the trephine, which will give the patient a 
tolerable chance of a permanent cure. 

If there is evidence of inflammation, or thickening of the membranes 
of the brain, or spinal cord ; cups, wet or dry, blisters, or pustulation 
with tartar emetic ointment should be persevered in, to the back of the 
neck, or along the spine, according to the seat of the disease, till it is re- 
moved as far as may be. This course of counter-irritation, with an 
occasional saline cathartic, a plain diet taken with regularity, and a strict 
avoidence of every cause capable of producing, or increasing the general 
excitability of the nervous system, and especially irritation of the brain, 
will generally best fulfill the indications in epilepsy, from cerebral, or 
spinal meningitis. 

In scrofulous cases, in which there is danger of tuberculous deposits, 
or of serous effusion into the arachnoid cavity, or into the ventricles of 
the brain ; in addition to what I have suggested, the iodide of potassium 



EPILEPSY. 275 

or the syrup of the iodide of iron should be given, in moderate doses, and 
continued for a long time, with, or without cod liver oil. This course of 
treatment in epilepsy, from such conditions, may not effect a cure : but 
I am satisfied that it is clearly indicated, and that it may palliate the 
disease, and perhaps prevent an early fatal termination. 

In cases in which there is evidence of softening of the brain, from 
masturbation, excessive venery, &c, the patient should be prohibited 
from further abuse of himself; should avoid all manner of excitement; 
should be placed upon a plain, digestible, and nourishing diet, to be 
taken with regularity, and should take for a long time some preparation 
of iron for the blood, and the oxide of zinc as a tonic for the nervous 
system. In such cases, three or four grains of the carbonate of iron, 
with an equal quantity of the oxide of zinc, may be given three times 
per day, after each meal, and continued for as long a time as the patient 
continues to improve from its use. 

In the treatment of cases of epilepsy in which the local irritation is 
situated at some point distant from the brain, the brain being irritated 
sympathetically, the remote causes should be sought out and removed, 
and then the local irritation or derangements treated on general princi- 
ples, whether it be in the liver, kidneys, womb, or alimentary canal. If 
the local irritation or derangement, of which the cephalic irritation is 
symptomatic, can be removed in such cases, the sympathetic irritation 
of the brain will generally subside, and hence the epileptic paroxysms 
will no longer occur. 

In cases of epilepsy in which the cephalic irritation or congestion is 
symptomatic of disease of the liver or kidneys, of an inflammatory or 
functional character, the treatment should be directed to the affected 
organ, and counter-irritants, alteratives, diuretics, &c, used according 
to the nature of the morbid condition, till the healthy hepatic or renal 
functions be restored. When this is accomplished, the patient may 
require gentle vegetable or mineral tonics for a few weeks, and perhaps 
months, to correct the fluids and solid tissues of the body, and to break 
up the tendency to the disease, which the epileptic paroxysms have pro- 
duced. 

If vegetable tonics be required, the fluid extracts of cinchona or of 
Colombo will generally do best. From thirty to sixty drops of the fluid 
extracts of either may be given in such cases, before each meal ; and if 
the blood and nervous system require tonics, from three to five grains 
each of the carbonate of iron and oxide of zinc may be given three times 
per day, after each meal, and continued as long as the patient improves 
under their use. With such a plan of treatment, a regulated diet, and 
a careful avoidance of all the causes calculated to perpetuate the disease, 
many epileptics may be greatly benefited, and some cases permanently 
cured. 

In cases in which the womb is the primary seat of irritation, with 
menstrual irregularities, the treatment should be directed to that organ, 
and by a judicious treatment, adapted to each particular case, the irrita- 
tion subdued, and the menstrual secretion restored. When this is 
accomplished, if the epileptic disease continues, a tonic course of treat- 
ment similar to that suggested above, which shall exactly fulfill the indi- 



276 DISEASES OF THE NERVOUS SYSTEM. 

cations which arise, should be continued while the patient continues to 
improve. 

If the alimentary canal be the seat of primary irritation, it may be 
from indigestion or from verminous irritation. If from the latter, an- 
thelmintics suited to the case should be administered, and the offending 
cause removed, after which the case should be treated according to the 
principles I have already laid down, with vegetable or mineral tonics, or 
both, according to the indications which arise. 

If the gastro-intestinal irritation be from indigestion, it is generally, 
according to my observation, the result of imprudence in eating and 
drinking ; and if the patient be a child, from eating between meals, and 
perhaps if an adult. In such cases the patient should be allowed a 
plain, digestible and nourishing diet, to be taken invariably at regular 
meal hours, and on no account anything between meals. To improve 
the digestion, allay the gastro-intestinal irritation, and to improve the 
blood and nervous system, a pill composed of rhubarb, extract of conium, 
carbonate of iron and oxide of zinc, of each one grain, with a little gin- 
ger, may be given three times per day, after each meal, and continued 
till a permanent cure is effected. With this pill alone, and a regulated 
diet, as well as regular hours of taking food, I have succeeded in perma- 
nently curing two epileptics of this character, in one of which the fits 
had continued for ten years, and in the other, a little less than that 
time. 

Thus it may be seen, we have the principles which are to guide us in 
the treatment of epilepsy, the grounds for every remedial measure being 
purely rational, thus leaving no occasion for empirical remedies, as there 
really is none in any disease, with which the human family are afflicted. 

There is no disease with which I am acquainted, in which so much 
can be ckne by way of correcting various imprudences, such as irregular 
eating and drinking, masturbation, excessive venery, the use of tobacco, 
drunkenness, licentiousness, &c, as in epilepsy. In fact, no prescription 
should ever be made in this or any other disease, without first getting at 
the imprudence which has led to it, and then demanding and enforcing 
its abandonment, as well as a strict observance of the laws of health and 
propriety. By taking this course, we go to work for the patient with 
his co-operation and assistance, but neglecting this essential preliminary 
measure, we may prescribe with the wisdom of an Esculapius, but the 
counteracting influence of the patient's imprudence will foil all our 
efforts, and be sure in the end to bring down upon our guilty heads the 
deserved anathemas of our patients and their friends. 

SECTION XI.— CATALEPSY. 

By catalepsy, from the Greek xattoaitys, "a seizure," I mean that pecu- 
liar disease of the nervous system characterized by a temporary suspen- 
sion of consciousness, sensorial power, and volition ; the body remaining 
in the precise position it was when the attack came on, without coma, 
muscular rigidity, or spasm ; the involuntary functions being carried on 
with little or no interruption. Catalepsy is a paroxysmal disease, each 
attack being the immediate effect of irritation and congestion of the 
brain, sufficient to suspend, for the time, the influence of the mind upon 



CATALEPSY. 277 

the body, through the medium of the brain and nervous system, but not 
sufficient to interrupt the generation and flow of nervous influence, by 
which the voluntary muscles receive their tone. 

Hence in catalepsy the voluntary muscles are not paralyzed as in 
apoplexy, or convulsed as in epilepsy ; but being shut out from the influ- 
ence of the mind or will, and receiving at least a partial supply of 
nervous influence, their tone is retained, and they consequently remain 
during a paroxysm in the precise position they were at the time of attack, 
unless they are moved by some other person, and then the part so moved 
remains in the new position in which it is placed. 

Symptoms. — The attack very generally comes on without any warning 
of its approach, but sometimes slight premonitory symptoms occur, such 
as vertigo, cephalalgia, a flushed face, forgetfulness, pain in the bowels, 
yawning, depressed spirits, and sometimes other symptoms indicative of 
slight cephalic congestion. When an attack occurs, every part of the 
body remains in precisely the same position it was at the moment of 
seizure. If the attack comes on while the patient is in the act of doing 
any thing, as eating or drinking, the hand remains in the precise posi- 
tion it was in till the paroxysm passes over. 

In a case of a boy, nine years old, that came under my care a few 
years since, from Lewis county, N. Y., I have known the paroxysm to 
come on at meal time, and while the patient was in the act of passing 
food to the mouth, the mouth also being open. Not a motion would be 
made, either with the hand or mouth, till the paroxysm passed off, when 
the food would be carried to the mouth, as though nothing had happened. 
On another occasion he ran up a board, one end of which lay on the top 
of a fence, and when at the height, being seized with a paroxysm, he re- 
mained poised upon the extreme end of the board over the fence, till the 
paroxysm passed over, when he jumped to the ground as though nothing 
had happened. 

The eyes, during a paroxysm, are generally open, fixed, and slightly 
turned up, but sometimes they are spasmodically closed. The extraor- 
dinary peculiarity of this affection consists in the tendency of a limb or 
part to remain in the precise position in which it is placed, even though 
it be the most awkward, as that of a hand high above the head. In 
complete catalepsy the sensorial functions are entirely suspended, and 
the patient on recovering, remembers nothing of his own sensations, or 
of what has been doing about him during the paroxysm. 

If a cataleptic attack comes on while the patient is conversing, and 
during or interrupting a half pronounced word, as soon as the paroxysm 
is over, the word will generally be finished, and the conversation con- 
tinued as though nothing had happened. In very mild cases, a slight 
degree of sensorial power remains, and the patient retains an indistinct 
recollection of what had taken place during the paroxysm ; but in very 
severe cases, there is not only a suspension of the sensorial power, but 
the involuntary functions of respiration and circulation are partially in- 
terrupted or quite imperfectly performed. 

The duration of a cataleptic paroxysm varies from a few minutes to 
several days, but in the majority of cases, it does not exceed two minutes, 
at least such has been the result of my observation. There is generally 
no regularity in the return of the cataleptic attacks. They may come 



278 DISEASES OF TIIE NERVOUS SYSTEM. 

on several times in a day, or only once in several days, weeks, or even 
months ; but I think in most cases they recur either every day or every 
few days. 

Severe cases of catalepsy sometimes terminate in epilepsy, an increase 
of the cephalic congestion not only interrupting the mental functions, 
but also so far interrupting or deranging the generation, flow, and dis- 
tribution of nervous influence, as to produce convulsions of the voluntary 
muscles, as an increase of the cephalic congestion in epilepsy may pro- 
duce apoplexy. 

Diagnosis. — The diagnosis of catalepsy is attended with little or no 
difficulty, as there is no other disease in which the different parts of the 
body retain their exact position during an unconscious state. 

Causes. — The causes of catalepsy are various, such as irregular eating 
and drinking, intestinal worms, masturbation and sexual excesses, the 
use of tobacco, drunkenness, licentiousness, &c, in all respects similar 
to those which produce epilepsy. But catalepsy occurs most frequently 
in young females, coming on apparently in consequence of a nonappear- 
ance of the menses, or else from their partial or total suppression after 
they have been established. It may occur, however, in either sex, and 
at any age, from intense mental application, violent anger, protracted 
grief, hatred, terror, and many other like causes. Finally, every variety 
of imprudence or abuse capable of producing epilepsy may act as a cause 
of catalepsy ; but next to menstrual irregularities, I believe the disease 
is most frequently produced by gastro-intestinal irritation, from irregular 
eating, or from taking, at all hours, crude, unwholesome, and indigestible 
articles of food. 

Pathology. — In relation to the pathology of catalepsy, it appears to 
consist in an irritable condition of the whole nervous system, including, 
of course, the brain ; the paroxysms being brought on by any cause 
capable of producing a slight congestion of the brain. This congestion 
may be either in a sthenic or an asthenic patient ; in the one case, being 
of an active, while in the other, it is of a passive character. 

In catalepsy occurring in plethoric or sthenic patients, the paroxysms 
are usually more violent and protracted than in cases in which there is 
slight debility, and the paroxysms brought on by passive congestion of 
the brain. The reason why epilepsy or apoplexy is not produced instead 
of catalepsy, is because of the less intensity of the cephalic congestion, 
leaving the brain the ability to generate and convey to the muscles suffi- 
cient nervous power or influence to keep up the tone of the muscles, 
while the power of the mind, or will, over the physical organization is 
for the time entirely suspended. 

In those severe cases of catalepsy which terminate in epilepsy, the 
cephalic congestion becomes sufficient to produce convulsions, while in 
very slight cases of catalepsy, the degree of the cephalic congestion is 
not sufficient to completely destroy or suspend consciousness, so that the 
patient may have an imperfect recollection of what occurs during the 
paroxysm. It is possible, too, that in catalepsy the congestion of the 
brain may not be so much of the cerebellum as in epilepsy, and that 
may be a reason, in part, for the absence of convulsions in patients with 
catalepsy. 

In those cases of catalepsy which occur from irritation of the stomach 



CATALEPSY. 279 

and intestines, the brain becomes affected to irritation through the sym- 
pathetic nerves, and, consequently, more or less congestion of the brain 
occurs, which produces or develops the cataleptic paroxysm. The same 
is also true in all sympathetic cases, no matter at what point away from 
the brain the primary local irritation is located. There appears, then, 
to be nothing very mysterious in this affection, or its symptoms, when 
we take into account the nature of the disease, and the various functions 
of the brain and nervous system. 

Prognosis. — The prognosis in catalepsy is not generally very unfavor- 
able so far as a fatal termination is concerned, but the patient may pass 
on to an epileptic state, and this finally to apoplexy, and thus the patient 
may perish. Many cases however, terminate spontaneously, while a 
much greater number recover by the removal of the cause or imprudence 
which has produced them, together with a strict observance of the laws 
of health, and a careful judicious course of medical treatment. 

Treatment. — The treatment of catalepsy should be on strictly rational 
principles, and does not differ in its indications materially from those of 
epilepsy. In every case the cause should be sought out and removed if 
possible, and then the attention and treatment should be directed to the 
general condition of the patient, and to the primary seat of the local 
irritation, which either directly or sympathetically irritates the brain 
and produces the cephalic congestion, upon which the paroxysms depend. 
If the patient be plethoric, general and local bleeding may be indicated, 
with an occasional saline cathartic, but if the patient be anaemic, a tonic 
course of treatment, with alcetic purgatives from the first is clearly indi- 
cated. 

If the irritation which produces the attack be primarily of the brain, 
or spinal cord, after a general bleeding and a saline cathartic, if indi- 
cated, cups, wet or dry, over the seat of the cerebro-spinal irritation, re- 
peated at intervals of a few days at first, will generally do well, and later, 
blisters or pustulation with tartar emetic ointment to the back of the 
neck, or along the spine, may be indicated, and should not be neglected. 

Having thus subdued the cerebro-spinal irritation the cataleptic parox- 
ysms may disappear, but it generally becomes necessary, to place the 
patient on a restricted, plain, digestible diet, to insist upon a reasonable 
amount of exercise, to avoid any undue physical or mental excitement, 
to keep the bowels regulated by an occasional saline cathartic, and to 
enforce a strict observance of the laws of health in every respect. 

In cases of catelepsy in which the irritation and congestion of the 
brain is sympathetic of a primary irritation in some part of the system 
remote from the brain, as in the liver, kidneys, uterus, or alimentary 
canal, after removing or correcting the imprudence which has led to it, 
the general condition of the patient being taken into account, the treat- 
ment should be directed to the organ or part primarily affected. 

If the liver or kidneys be the seat of primary disease or derangement, 
cups, counter-irritants, alteratives, and diuretics may be indicated, and 
if so, should be judiciously persevered in till the hepatic or renal disease 
be subdued and a healthy action restored, and then the case should be 
submitted to that course of treatment best calculated to restore a healthy 
state of the nervous system, which being accomplished, the cataleptic 
disease may disappear. 



280 DISEASES OF THE NERVOUS SYSTEM. 

In cases of catalepsy in which there are menstrual irregularities, 
operating as the primary derangement, that function should be restored 
by a judicious course of treatment, and then the case treated if neces- 
sary, on general principles, till the blood and nervous system are restored 
to a healthy state. 

If the disease depends upon gastro-intestinal irritation from worms or 
from imprudence in eating, these causes should be corrected ; the worms 
being removed by remedies the least liable to produce or increase the 
irritation of the alimentary mucous membrane, and then the case treated 
with tonics, &c, if necessary, till the paroxysms cease. 

In those cases which occur from indigestion, the result of irregular 
eating, the patient should be placed upon a plain, digestible and nourish- 
ing diet, to be taken at regular meal hours, and the indigestion and 
gastro-intestinal irritation corrected as well as the state of the blood and 
nervous system, by small doses of rhubarb, extract of conium, carbonate 
of iron and oxide of zinc; a pill of one grain of each, with a little ginger, 
after each meal, as I suggested for epilepsy, will, I believe, best fulfill 
the indications in such cases. In cases of catalepsy from general nervous 
irritability, without any local disease, the result generally of masturba- 
tion, sexual excesses, the use of tobacco, drunkenness, licentiousness, &c. ; 
after removing the cause, the pill I have suggested above may do very 
well, or small doses of the citrate of iron, one or two grains, after each 
meal, and ^th or ^th of a grain of strychnia before each meal, con- 
tinued for a long time, may be indicated. 

SECTION XII.— CHOREA— (£*. Fitus's Dance.) 

By chorea, from the Greek zopua, "a dance," I mean that peculiar 
disease of the nervous system, in which, without loss of consciousness, 
the voluntary muscles are rendered, in a greater or less degree, uncon- 
trollable by the dictates of the will. In slight cases, the influence of the 
will over the voluntary muscles is only very slightly impaired, and hence 
the irregular action of the muscles is not very marked ; but in very 
severe cases the nervous derangement is so great that the voluntary 
muscles are rendered almost independent of the influence of the will, at 
least for a part of the time. 

Symptoms. — Chorea generally makes its appearance very gradually, 
under a variety of premonitory symptoms, varying in duration from a 
few days to several months, and marked by a deranged state of the di- 
gestive organs and nervous system. The most common of these premoni- 
tory symptoms are flatulent pains in the stomach and bowels, variable 
appetite, constipation, with a tumid and hard abdomen, vertigo, anxiety 
and oppression in the precordial region, tremors of the extremities, 
oppression in the chest, palpitation, fullness of the head, confusion of 
mind, itching in the nose, cold feet, and a general nervous and irritable 
condition of the system. 

After these premonitory symptoms have continued for a longer or 
shorter time, irregular spasmodic contractions are observed in some of 
the voluntary muscles ; frequently of the face, or one of the extremities. 
These spasmodic or imperfect voluntary motions of the part or parts are 



CHOREA. 281 

at first slight and may only occur from physical or mental excitement. 
Gradually, however, these involuntary, or imperfect unsteady voluntary 
movements become stronger and more constant, till at times almost every 
muscle of the body is in a state of continued involuntary action. In 
some cases, this irregular muscular action is confined to one side of the 
body, or to a particular part ; but generally it extends more or less to all 
the voluntary muscles. 

From the imperfect command of the will over the voluntary muscles, the 
patient when he attempts to walk has a starting, hobbling, and irregular 
gait, with an awkward dragging, in some cases, of one of the legs. In 
some very severe cases, the empire of volition over the voluntary muscles 
is so completely lost that progression and even the erect posture are ren- 
dered utterly impossible. The hands and arms are usually in constant 
motion, the patient being unable to direct them, and frequent ineffectual 
efforts are made before the hands can be brought to the desired point. 
In attempting to carry food to the mouth, the hand is carried in almost 
every direction before it finally succeeds in reaching the mouth, the head 
being sometimes thrown from side to side, or backward and forward, and 
the mouth suddenly widely opened and then forcibly closed. 

Respiration is often anxious and irregular, the voice being altered, and 
articulation indistinct ; and in one case that fell under my care, the voice 
was entirely lost for a time. In severe protracted cases, the mind ap- 
pears materially disturbed, and the authority and commands of the will 
are almost entirely disregarded ; the whole muscular system being thrown 
into a state of insurbordination, its action being irregular, lawless, and not 
conducive to the general welfare of the system. Chorea sometimes assumes 
a very extraordinary character ; the patient being seized with paroxysms 
of violent dancing, with various antic contortions of the body, and ap- 
pears to have an almost irresistible propensity to leap upon chairs, tables, 
and to exhibit other like performances. 

During sleep, while volition is in a state of temporary suspension, all 
the spasmodic motions which characterize this affection cease entirely. 
Thus showing that the irregular action of the voluntary muscles, is owing 
to an effort of the will to command them ; but on account of the deranged 
condition of the nervous system, this command is imperfectly obeyed, and 
thus the irregular motions of the limbs, and other parts may be accounted 
for. Chorea is sometimes a paroxysmal affection, the irregular motions 
coming on by turns. But in most cases that have fallen under my ob- 
servation, the irregular muscular motions have been continuous, during 
the waking hours. 

Anatomical Characters. — In many cases in which death has occurred 
from chorea, or in which the patient has died from some accidental cause, 
the brain, spinal cord, and nerves, have been found in an apparently 
healthy state. It is therefore probable, that in those cases in which there 
has been found a serous effusion into the ventricles of the brain, and into 
the meningeal cavity of the spinal cord, injection of the meninges of the 
brain, or softening of the brain or spinal cord ; that the conditions are 
accidental, and not a necessary morbid appearance in this disease. 

Diagnosis. — The only conditions with which chorea is liable to be con- 
founded, are mild cases of epilepsy, and certain forms of hysteria and 



282 DISEASES OF THE NERVOUS SYSTEM. 

paralysis ; but when we remember that in chorea there is neither, coma, 
delirium, or rigid spasms, but only such symptoms as arise from an im- 
perfect control of the will over the voluntary muscles, the diagnosis may 
be rendered clear. 

Causes. — According to my observation chorea usually attacks children 
between the eighth and twelfth years of age ; but it may occur earlier 
than this, and in some rare cases it may occur in persons of even ad- 
vanced age. Chorea most frequently occurs in patients of a nervous 
temperament ; thus indicating that its development depends upon a de- 
ranged condition of the nervous system, by which the nerves supplying 
the voluntary muscles, become imperfect conductors of the dictates of 
the will. 

Any cause then, capable of rendering the nervous system weak and 
irritable, may act as an exciting cause of chorea. Among the most fre- 
quent, are mental emotions, especially terror, fear, and religious en- 
thusiasm, gastro-intestinal irritation from crude articles of food, worms, 
&c, and the accumulation of irritating substances in the intestines. But 
there are other causes which often appear to produce chorea, such as re- 
pulsion of cutaneous eruptions, the suppression of habitual discharges, 
over-excited sexual propensities, and the ruinous habit of taking food at 
irregular hours, or between meals. 

Pathology. — The real nature of this disease appears to consist in a 
weak, deranged, and irritable condition of the whole nervous system, 
including, of course, the bran, and especially the cerebellum, as well as 
the spinal cord ; but not necessarily connected with any local lesion, 
organic disease, or even congestion. The disease, then, is functional, 
and it is probable that the nerves are involved as well as the brain, and 
it appears to me in a greater degree, for the brain appears capable of 
generating the nervous power, and also of receiving from the mind the 
dictates of the will ; but as this impression of the will is sent forth on 
the nerves, which supply the voluntary muscles, it is very much like 
sending a locomotive on a deranged track — confusion and irregular mus- 
cular action being the result. 

Prognosis. — The prognosis in chorea is generally favorable, as most 
cases, under proper treatment, finally recover. Only one fatal case has 
fallen under my observation, and that I suspect was at first neglected, 
which may account for its fatal termination. 

Treatment. — The indications in the treatment of chorea are plainly to 
remove the cause, to overcome any local or general cause which may be 
irritating the nervous system, and then to restore the blood, and also the 
tone of the nervous system. The cause should be sought out at once, 
and whether it be irregular eating, masturbation, or any other impru- 
dence, it should be corrected or removed, and the patient made to take 
a plain, digestible, and nourishing diet, with regularity ; and to conform 
rigidly, in every respect, to the laws of health and propriety. 

In those cases that have been produced by mental emotions, the 
greatest care should be exercised to remove or avoid that source of 
nervous excitement, after which the patient should be put upon a tonic 
course of treatment. That which I have found to do best, as a tonic _ for 
the blood, for the nervous system, and to improve digestion, is a combina- 



INSANITY. 283 

tion of carbonate of iron, oxide of zinc, and rhubarb, given in powder, 
after each meal, so that five grains of the iron, three grains of the zinc, 
and two grains of rhubarb shall be given at a dose. 

In very debilitated cases, if a nervous stimulant be indicated, half a 
drachm of the fluid extract of the cimicifuga racemose may be given 
three times per day, before each meal, for a time, with very happy 
effects : or instead of this a grain or two of ginger may be given with 
each dose of the iron, zinc, and rhubarb, after each meal. 

In those cases in which the nervous irritability or derangement has 
been brought about by gastro-intestinal irritation, from worms or re- 
tained fecal matter, a cathartic of calomel and castor oil, or oil of turpen- 
tine if it be worms, should be administered. And if slight constipation 
continues, a pill of a grain of rhubarb and two grains of aloes should be 
continued, after dinner each day, and the combination of iron, zinc, and 
rhubarb, with or without a little ginger, given as suggested above, and 
continued till a cure is effected. 

In cases in which there is suppresion of the menses, causing or com- 
plicating the nervous irritability, after using proper cathartics, a pill of 
the sulphate of iron, extract of gentain, and rhubarb, of each a grain, 
with half a grain of ginger, taken after each meal, will often best fulfill 
the indications. Pursuing the principles I have here laid down, I have 
generally succeeded in the treatment of this disease. 

SECTION XIIL— INSANITY. 

By insanity I mean that peculiar disease of the nervous system, 
including of course the brain, in which the mind fails to communicate 
and receive correct impressions ; the disease being purely physical and 
not of the mind, which being a spirit is not liable to disease. 

Now the mind, being a spirit, is capable of existing independent of 
the body, of thinking, acting and reasoning within itself, as it will after 
the death and decomposition of our bodies ; but our bodies are the 
instruments of our minds in our present state, the nervous system, 
including the brain, being the only part of the physical organization 
through which the mind can act. It is my opinion that the whole 
nervous system is properly the organ of the mind ; but it is probable 
that the cortical or gray matter of the brain is the more essential seat 
or organ with which the mind immediately communicates, receiving from 
it and communicating to it all impressions sent forth, or received by the 
mind though the physical organization. 

It is probable that the impressions so sent forth by the mind through 
the gray matter of the brain, is communicated to different parts of the 
body through the white tubular matter of the brain, spinal cord and 
nerves ; while impressions from without are received through the senses, 
and communicated through the nerves, spinal cord, and white tubular 
matter of the brain to the gray matter of the hemispheres, and through 
this gray matter directly to the mind itself. It is probable that the 
cerebellum so far influences impressions sent forth by the mind to the 
voluntary muscles, as to insure harmony in all the minute muscular 
motions, such as arc necessary in standing, walking, running, &o, 



284 DISEASES OF THE NERVOUS SYSTEM. 

If now we bear in mind that the intellectual principle is a spirit, 
possessing powers, faculties and properties of its own ; and that our 
bodies are mere instruments of our minds furnished by the Creater for 
the purpose of enabling mind to communicate with mind, and with the 
material world ; the phenomena of insanity is really no mystery. In 
fact, when we remember, the functions of each part of the nervous 
system, and that it is the only medium through which the mind receives 
and communicates impressions, all the phenomena of insanity are just 
what might be expected to arise ; varying of course with the seat, 
nature, and extent of the disease or derangement of the nervous system. 

In a healthy state of the nervous system, the mind receives and 
communicates ideas or impressions in a correct, plain and rational 
manner, so that the mind is not deceived through the senses from ex- 
ternal objects, and the ideas which the mind sends forth to other minds, 
are communicated correctly, and hence we call the person rational or 
sane. But if from any considerable cause the brain or any part of 
the nervous system becomes sufficiently deranged, the channel of com- 
munication becomes more or less interrupted, and the ideas, though they 
may be rational in themselves, are imperfectly conveyed through the 
shattered or deranged brain and nervous system, and so we call the 
patient insane. 

Now the degree of insanity will depend upon the degree of physical 
derangement of the brain and nervous system, but especially of the 
cortical or gray matter of the brain. If from meningeal inflammation the 
cortical matter of the brain becomes more or less involved, there may be 
an entire interruption to the communication of ideas to and from the 
mind, in a rational manner at least, and this constitutes mania. 

In cases in which there is only a limited degree of cephalic derange- 
ment, of either an inflammatory or congestive character, involving per- 
haps only a limited portion of the gray matter of the brain ; or if general 
which to me appears the more probable condition in such cases, the con- 
gestion and derangement being brought on only by a particular subject, 
we have insanity upon one subject, or monomania. 

If now, instead of an inflamed or actively congested condition of the 
meninges and gray matter of the hemispheres, we have an anaemic, re- 
laxed, debilitated, and perhaps irritable state of this cineritious portion 
of the cerebral matter, with perhaps more or less passive congestion, 
there may be a multitude of ideas or impressions communicated to and 
from the mind, but it is so imperfectly done, that there is a want of 
coherence or connection between them, and this constitutes dementia. 

When from various derangements of the nervous system, the 
mind has long been deceived by false impressions or impressions commu- 
nicated to it through deranged organs of sense, the mind fails by degrees 
to appreciate those principles of utility, order, or morality, by which it 
should be governed, and this constitutes moral insanity. 

And finally, if from protracted inflammation of the brain or its meninges, 
or from any other cause, sufficient disorganization or morbid changes 
occur in the gray matter of the brain, to utterly destroy its capacity for 
communicating impressions to and from the mind, the mind though sane 
and rational within itself, is cut off from communicating with other minds, 
and with the material world, and this constitutes idiocy. 



INSANITY. 285 

Hence we have, as the result of different degrees and varieties of 
derangement of the nervous system, involving to a greater or less extent, 
probably in every case, the gray matter of the hemispheres of the brain, 
mania, monomania, dementia, moral insanity, and idiotism ; the symp- 
toms of each of which we will now proceed to consider. 

MANIA. 

Symptoms. — The symptoms of mania differ widely in different cases ; 
they are generally, however, so obvious and well understood that no more 
than a general description need be given of the peculiar symptoms of each 
variety. In mania there is generally a rapid succession of incoherent 
ideas and violent excitement of the passions, expressed by great agitation, 
loud vociferations, singing and fury, just as might be expected when we 
remember that the mind is deceived by impressions received through the 
senses, and that the ideas or impressions sent forth by the mind are com- 
municated through a deranged track or channel of communication. 

Mania is usually preceded by a marked change in the habits, tastes, 
attachments and passions of the patient. The patient is generally either 
animated, irritable, jealous or wayward. The patient may be eccentric 
in his conversation, viscious in his disposition, may sleep little or be 
harrassed with dreams, and he often forms extravagant plans either to 
increase his fortunes, or for the public good. Sometimes he engages in 
ruinous speculations, squanders his means in extravagant amusements, or 
in unnecessary articles of clothing, or allows himself to be cheated by 
bad bargains, &c. 

While this train of premonitory mental symptoms are being developed, 
the patient is often afflicted with constipation of the bowels, irregular 
appetite, vertigo, cephalagia, a sense of throbbing in the head ,a wild 
expression of the eyes, and a general feeling of restlessness, uneasiness 
and irritability ; indicating slight congestion and irritation of the brain, 
which condition is evidently producing the deranged mental phenomena. 
But as the cephalic congestion, irritation, and meningeal or cerebral in- 
flammation becomes fully developed, the expression of the countenance 
is wild and often ferocious ; the eyes are prominent, sparkling, and in 
constant motion ; the patient sings, whistles, walks to and fro with 
rapidity, or stands still with his hands and eyes directed towards some 
real or imaginary object; and in some cases the patient fails to sleep for 
many successive nights. 

The pulse may be full, strong and frequent, but it is often after a time 
very irregular, unnatural, and sometimes intermittent. The skin is at 
first hot and dry, but later it may become cool, and perhaps covered with 
a profuse perspiration. The sensorial organs are apt to be excitable, 
the appetite variable, the bowels constipated, and the urine high-colored 
and small in quantity. During this inflammatory or highly irritated 
state of the brain and its meninges, the mind forms erroneous perceptions 
of the impressions of external objects on the senses, or the senses convey 
erroneous impressions to the mind, and impressions sent forth from the 
mind are imperfectly communicated in consequence of derangement in 
the channel or medium of communication. 

In consequence of this derangement in the communication of impres- 



286 DISEASES OF THE NERVOUS SYSTEM. 

sions, the patient may mistake friends for strangers ; may take the kind- 
est words or treatment as the highest abuse, and may even suppose him- 
self conversing with persons that are silent in his presence, or even 
with imaginary beings. On the other hand, ideas or impressions of the 
patient, perhaps rational in themselves, are so imperfectly communicated 
to those around him, that they by no means express the feelings or senti- 
ment of the mind of the insane; the patient often expressing curses and 
violence when really the mind intended no such thing. 

In consequence of this deception of the patient through his senses and 
also from the inability of the mind to communicate its real impressions, 
the empire of volition appears at times entirely suspended, and the 
patient is really no longer master of his own determinations ; he may in- 
jure himself, or inflict injuries upon others; tear his clothes; leap out 
of windows, and commit various acts of fury. 

Such are the ordinary symptoms of acute mania, as it has developed 
itself in most cases that have fallen under my observation ; but as the 
irritation or inflammation of the cerebral hemisphere, or their meninges 
gradually subsides, or is subdued, the mania may cease, or it may assume 
a chronic form. When acute mania thus assumes a chronic form, or in 
cases which are chronic from the first, instead of the highly excitable 
condition of the acute state, the physical symptoms are those of chronic 
inflammation of the brain or its meninges, or of some morbid change in- 
volving the gray matter of the hemispheres. 

The mania in this chronic state may be continued, remittent, or even 
intermittent ; but in either case, as the cephalic disease assumes a more 
passive or chronic form, the patient has a sullen or downcast look; he is 
apt to neglect his dress and person, and in many cases that have fallen 
under my observation, there has been an apparent indifference to sur- 
rounding objects. 

Thus we have the most common symptoms of both acute and chronic 
mania, as they have been developed in cases that have fallen under my 
observation. But it must be remembered, that as no two cases have ex- 
actly the same degree of physical derangement, upon which the mania 
depends, there must of necessity be a variety of symptoms developed in 
different cases, and also in the same cases in different stages of the dis- 
ease. 

MONOMANIA. 

Monomania consists, as we have seen, in an insanity upon one subject, 
while on all other subjects the patient may appear quite rational. 

The symptoms of monomania differ widely in different cases, as it in- 
cludes hypochondria, fanaticism, melancholy, misanthropy, and, as I be- 
lieve, what has been called insane impulses, depending generally upon 
the degree and extent of the physical derangement, and also in part 
upon the topics which have been uppermost in the patients mind pre- 
vious to the insanity. 

In hypochondria there is -generally preceding the mental disturbance 
more or less physical derangement for some length of time, such as indi- 
gestion, flatulence, constipation, a furred tongue, a dry skin, a sallow 
complexion, cold feet, disturbed sleep, and especially is the patient apt 






INSANITY. 287 

to complain of pains in the chest or abdomen under the false ribs, which 
symptom has given the name to this variety of insanity. 

After these physical ills have continued for a time, the nervous 
system becomes very sensibly involved, and probably some portion, or 
even all the gray matter of the hemispheres of the brain especially so ; 
and then the mind being deceived by every symptom being magnified 
through the shattered nervous system exhibits monomanical symptoms. 

The morbid condition of the gray matter of the brain may be partial 
in such cases, and thus the insanity upon one subject be accounted for ; 
but it appears to me more probable that it is general, and that it is irri- 
tation from congestion of the cephalic vessel; the congestion and its 
attendant irritation being produced whenever the mind calls up the 
favorite topic of health, and thus the impressions to and from the mind 
are magnified or deranged, and hence the monomania on that subject. 
The patient, under such circumstances, is apt to suppose himself afflicted 
with consumption, cancer, intestinal worms, liver complaint, syphilis, and 
a host of other distressing, loathsome and dangerous affections; and 
what is more, in many cases no course of reasoning appears capable of 
reaching his mind to correct the delusion. 

Fanaticism is another form of monomania, most liable to be developed, 
I believe, from religious or political excitement ; the physical derange- 
ment consisting in an excitable, irritable condition of the nervous sys- 
tem, involving, of course, the cerebral hemispheres. In cases of this 
kind, the mind is apt to dwell upon its peculiar theme, whether it be of 
a religious, political or other character, till the concentrated influence of 
the mind overtaxes the nervous system, and therefore rational ideas are 
not communicated through the brain and nervous system ; but when the 
mind is called off upon other subjects, ideas are communicated quite 
rationally. 

If religion be the theme upon which the patient has become a mono- 
maniac, the patient is apt to believe that he has received some direct 
revelation, or that he is commissioned of God to perform some important 
or miraculous mission not within the sphere of mortals. If politics be 
the theme, the patient is apt to suppose himself fitted for some important 
office, to which he believes he has every prospect of being promoted. 
One monomaniac, that fell under my observation during the administra- 
tion of a late President, supposed that he was destined for the presiden- 
tial chair, which, however, was to be brought about by the help of a 
large army. While laying his plans, and explaining them, he mischiev- 
ously remarked to me, that he thought the President, calling him by 
name, would regret having taken the chair. 

Melancholy is another form of monomania, in which the nervous sys- 
tem is generally reduced to a weak, irritable, and deranged condition ; 
the result generally of some debilitating agent or pernicious habit, or 
else of protracted grief; the nervous system in either case being un- 
strung, whenever the prominent theme of misery is called up by the 
mind, but serving quite well as a conductor of impressions if the mind be 
called off upon other subjects. In some persons the depression and gloom 
become so great that the patient has a strong suicidal tendency, in some 
cases desiring to destroy himself to get rid of the burden of life, while 



288 DISEASES OP THE NERVOUS SYSTEM. 

in others he may regard it as a duty, which has perhaps been revealed 
to him, and with which he thinks it would be an unpardonable sin not 
to comply. In some cases, again, melancholy leads the patient to destroy 
his family, either to better their condition or to save them from some 
real or imaginary impending disgrace, or calamity, which is supposed to 
be pending. 

Misanthropy is another form of monomania, in which the derangement 
of the nervous system is often brought on by a train of unfortunate cir- 
cumstances, in which the patient has in reality, or in imagination, been 
unkindly treated by his fellow men. The effect of this kind of monoma- 
nia in some cases is to make the patient a silent, sullen hater of his 
fellow men ; the patient regarding it as a righteous indignation ; while 
in other cases the most revengeful disposition to homicide is developed. 
In either case, the condition is a fearful one, and may lead to the most 
fearful consequences, unless reasonable precautions and proper restraints 
be resorted to, to prevent the patient from injuring himself or his fellow 
creatures, from whose hands he often believes he has received such high- 
handed and unmerited abuse. 

Insane impulse is the last form of monomania which I will mention, 
as entitled to a separate consideration. This variety of monomania ap- 
pears to be the result of a blind impulse, coming on suddenly, to commit 
some crime without a motive, which the patient in his rational moments 
would by no means be guilty of. It most frequently occurs in persons 
of strong feelings and sympathies, and is the result of learning or wit- 
nessing some important serious or other event, such as an execution, a 
suicide, &c. 

I believe it may be accounted for in the same way that other cases of 
monomania must be. The person witnesses or hears of a case of suicide, 
or of an execution, or some other like event occurs, which, at the time, 
so far excites the sympathies as to produce a temporary rush of blood 
to or from the brain, during which state the person becomes temporarily 
insane. During this temporary state of insanity the patient may very 
possibly commit a homicide or suicide, according as the one or the other 
theme was occupying the mind, as the cause of the temporary mono- 
mania or insanity ; and yet the patient may not be in the least responsi- 
ble for the deed so committed. 

Great care should be exercised however in all legal proceedings, that 
this fact be not taken advantage of, to screen from justice the wretch 
who willfully and maliciously dyes his hand in the blood of his fellow 
man. Having thus completed our consideration of the symptoms of 
mania and monomania, let us proceed to inquire into those dementia. 

DEMENTIA. 

Dementia which consists, as we have seen, in that peculiar debilitated 
condition of the nervous system, in which there are a multitude of im- 
pressions or ideas conducted to and from the mind, in a disconnected or 
incoherent manner, may follow mania or monomania ; or it may be an 
orio-inal affection, the result of inflammation of the brain, and its men- 
inges. 

In cases of mania and monomania in which dementia supervenes, or 



INSANITY. 289 

when it occurs as an original affection, the inflammation of the brain and 
its meninges generally assumes a passive form, and, sooner or later, there 
is apt to occur a hesitancy of speech, weakness of the lower limbs, and 
more or less paralytic symptoms. As these physical symptoms are de- 
veloped, a multitude of ideas may be communicated to and from the 
mind ; but as the tone of the brain and nervous system is deranged, 
there is an association of unrelated perceptions — the ideas appearing to 
be collected together without any degree of order or harmony. 

There may be in such cases profound silence for a long time, as hap- 
pened in one case that fell under my care ; but there is apt to be great 
volubility of speech, with more or less bodily gestures, performed in con- 
vulsive rapidity. In dementia the mind appears fleeting and changeable, 
the patient being mild, malicious, generous, and miserly, all in the course 
of a few hours ; depending upon the weak, irritable, and deranged con- 
dition of the brain and nervous system. 

Dementia is apt to come on gradually, and may exhibit a variety of 
grades, from the slightest mental disturbance to a state approaching im- 
becility ; the patient being either silent or indisposed to speak, or else 
attempting or disposed to communicate his ideas, without the ability of 
doing it in a quiet and rational manner. 

In many cases the patient, unable to get off his ideas by speech, calls 
into aid the voluntary muscles, and hence the bodily gestures which are 
so often exhibited by patients in this condition. Thus we have the most 
common peculiar symptoms of dementia ; but it must be remembered 
that they are liable to great variations in different cases, and in different 
stages of the disease in the same case, like all other affections. 

MORAL INSANITY. 

Moral insanity consists, according to my view, in an inability to dis- 
cover those principles of order or morality which should govern or control 
every intelligent rational being. Hence a person morally insane may 
commit many acts of violence against his best friends, or fail to exercise 
that discretion and prudence which is always due from one person to 
another, whether friends or foes. 

This want of discretion, or common prudence, may be very trifling, or 
it maybe exhibited in falsehood, theft, violence, or even murder; re- 
quiring the greatest possible prudence on the part of friends or attend- 
ants to exercise a judicious restraint. The patient may appear physi- 
cally well. But.it will generally be found that such patients have led 
idle, vicious, and profligate lives ; disregarding in almost every respect 
the laws of health, which will account for the moral weakness or insanity. 

Now, to make moral insanity perfectly plain, it is only necessary to 
remember that the human mind is endowed by the Creator with an in- 
tuitive consciousness of self, and also an intuitive notion of God, while a 
knowledge of the material world is acquired through the bodily senses. 
Now, by the knowledge thus acquired, through the senses, the mind im- 
proves its knowledge of self, as well as its notions of God ; and by the 
sum of this knowledge, the mind learns its obligation to self, and its 
fellow beings, to God, and to all things ; and hence it may act in 
manner conducive to the greatest good of all. 
19 



290 DISEASES OF THE NERVOUS SYSTEM. 

Let now any human being pursue a reckless course of life, abusing bis 
bodily senses and nervous system generally by various imprudencies, 
such as the use of tobacco, gluttony, licentiousness, drunkenness, &c, 
and the mind forms very imperfect notions of the material -world, and 
consequently of self and of God. Now, as a consequence of this want 
of the essential" elements of knowledge, the person so situated forms no 
just conceptions of his obligations to himself, to his fellows, and to God; 
and hence the reckless disregard of the interests, welfare, and safety, of 
even near relatives, exhibited by patients morally insane. 

In this light, a person intoxicated is morally insane. His sense of 
obligation being while in that state deranged at least, and hence the acts 
of violence which are so often committed by persons in that deplorable 
condition, in some cases being of the most serious and fatal character. I 
believe that persons morally insane should have wholesome restraint ex- 
ercised over them. But legally, as in drunkenness, I believe it should 
be no palliation for crime actually committed. Thus we have the symp- 
toms peculiar to moral insanity, as well as the cause and manner of their 
development, there remaining only those of idiotism for our consideration. 

IDIOTISM. 

Idiotism consists, as we have seen, in such a hereditary or acquired 
condition of the brain and nervous system, that there is an utter inabi- 
lity on the part of the mind to receive and communicate impressions or 
ideas, however rational they may be in themselves. It may be conge- 
nital, or it may supervene upon other forms of insanity. It either case, 
it consists in a deranged condition of the nervous system, involving pro- 
bably in every case the gray matter of the hemispheres of the brain, 
either directly or indirectly. Whatever be the nature of the morbid 
change in the brain in different cases of idiocy, the function of the ner- 
vous system, including the brain is destroyed, at least so far as its being 
the organ of the mind is concerned. 

As there are no mental symptoms in utter idiocy, we have only to 
remember the vacant stare, the expressionless countenance, and the 
automatic movements, and the symptoms are all told. And sad indeed 
as is the picture, it would be doubly sadder if it were not for the fact, 
that the disease is physical, not of the mind, in congenital cases at least. 
For it is probable that the mind in such cases may be rational within 
itself, thinking, acting and reasoning by God-given powers. But as its 
instrument is useless, it has to think, act and reason within itself, with- 
out the ability of receiving or communicating a single idea. 

Thus then we have the peculiar symptoms of mania, mono-mania, 
dementia, moral insanity and idiotism ; as they have generally occurred 
in cases that have fallen under my observation and treatment. It 
should be remembered, however, that no two cases of any variety of 
insanity exhibit precisely the same symptoms, if we except perhaps utter 
idiocy, which really has no mental symptoms, and only antomactic phy- 
sical symptoms. 

Anatomical Characters. — The appearances presented on post-mortem 
examination of the bodies of persons that have died insane vary accor- 
ding to the nature of the insanity, and the period of the disease at which 






INSANITY. 291 

death has taken place. There may be various accidental morbid lesions 
of different parts of the system, as of the lungs, liver, alimentary canal, 
kidneys, &c, but by no means necessary conditions in insanity. But in 
additional to the accidental lesions, when they exist, and in fact in all 
cases in which death has occurred from insanity, or from accidental 
causes during insanity, the gray matter or cortical substance of the brain, 
together with the membranes of the brain exhibit signs of disease and 
generally of inflammation. In those cases of insanity which are com- 
plicated with more or less extensive paralysis, in addition to the signs of 
inflammation of the gray matter and membranes of the brain, there is 
generally a preternatural whiteness and induration of the medullary, 
tubular or white substance of the brain. 

The following then are the most frequent morbid appearances pre- 
sented in connection with insanity. The cranium may be thickened, and 
either hardened or softened, and in some cases more or less irregular in 
shape. Of the membranes, the dura mater is apt to be thickened and 
adherent, the arachnoid thickened and opaque with false membranes 
adherent to it, within its cavity ; and the pia mater swelled, red, infil- 
trated with blood or serum, and more or less strongly adherent to the 
brain in most cases at least. 

The cortical substance of the brain is reddened, sometimes generally, 
but in other cases in points ; its blood vessels are enlarged, and while it 
may be slightly indurated on its surface where it adheres to the pia 
mater, the portions beneath are apt to be softer than in health. In 
cases in which paralysis has occurred, the white or medullary portion of 
the brain is almost invariably found indurated. 

In protracted cases the bulk of the brain is often diminished, and 
minute cavities are found in the cortical substance, the result probably 
of former extravasation or else of softening. In chronic protracted 
cases the specific gravity of the brain may be diminished ; there may be 
serous or sanguineous effusion into the cavity of the arachnoid membrane, 
into the tissue of the pia matter, or into minute cavities in different 
parts of the encephalon, or finally into the ventricles of the brain in 
various quantities. 

Finally in conclusion, it is well to bear in mind, that among the morbid 
appearances thus presented, marks of disease, and generally of inflam- 
mation of the gray matter of the hemispheres, are a general, if not an 
invariable morbid condition in fatal cases of insanity ; and that in cases 
in which more or less paralytic symptoms have been developed, there is 
in addition, a preternatural whiteness, and induration of the white, ma- 
dulary, or tubular matter of the brain. 

Causes. — The causes of insanity, both predisposing and exciting, may 
be either physical or moral. The physical causes operate in most cases 
to derange the different organs, and their functions ; and thus either di- 
rectly, or indirectly the brain and nervous system, while the moral causes 
consist in an overaction of the mind, directly upon the brain and nervous 
system, the different organs and functions of the body becoming affected 
secondarily. 

Among the predisposing causes of insanity, both physical and moral, 
the most frequent are hereditary tendency, time of life, constitution, con- 
dition, education, celibacy, profession, and previous insanity. 



292 DISEASES OF THE NERVOUS SYSTEM. 

Hereditary predisposition to insanity consists in a pecularity of the 
physical organization, and especially of the brain and nervous system, by 
which the brain and its meninges are exceedingly liable to take on either 
active or passive inflammation, which condition, when it is produced by 
accidental causes, is liable to develop various forms of insanity. 

Time of life too, appears to have an influence in predisposing to in- 
sanity, as few cases occur in children, and it is not very common in 
advanced life, most cases probably occurring between the twentieth and 
fortieth years of age. Various causes may contribute to render insanity 
more frequent at this age, among which the embarrassments, and perplexi- 
ties attendant upon the commencement of the business transactions of 
life, may not be the least. 

A nervous temperament, whether inherited, or acquired from various 
imprudences in early life, is a strong predisposing cause of insanity, es- 
pecially if in addition the various passions predominate, such as pride, 
ambition, &c. 

Wealth and extreme poverty predispose to insanity ; the former by 
leading to idleness, and various excesses, and the latter by exposing to 
hardships, privations, distress, worriment, and unmerited neglect. 

Education, if attempted too early, or neglected, or what is worse, if it 
be of an improper vicious character, predisposes to insanity. If attemp- 
ted too early, the brain is rendered irritable, and hence only slight causes 
may lead to inflammation of the brain, and its meninges, and so insanity 
in some form may be the result. If it be neglected altogether, or if it 
be of a vicious improper character, the mind fails to form correct notions 
of its obligations, and hence a strong predisposition to insanity, and es- 
pecially moral insanity is the result, which only requires the continuation 
of the unfavorable beginning to develop the disease in mature years. 

Celibacy in both sexes, appears to predispose to insanity, perhaps in 
part from physical causes ; but more frequently I suspect from moral 
cause ; the unmarried, as a general rule, being more dependent upon 
strangers for many of the necessaries and comforts of life ; and besides, 
the cares and perplexities of life, though perhaps fewer are more apt to 
be shared alone in most cases. 

Profession predisposes to insanity ; those whose business require a 
constant exercise of the mind upon the brain, such as artists, poets, poli- 
ticians, and professional men, being by far more strongly predisposed to 
insanity, than those who pursue a tranquil course of life. Finally, one 
attack of insanity by the change that is apt to take place in the brain, 
and its meninges, strongly predisposes to another, for some time at least, 
and probably during the whole subsequent period of life, in most cases. 

The exciting causes of insanity are very numerous, embracing every 
imprudence, whether physical or moral, capable of irritating the brain, 
and of producing inflammation of the brain or its meninges, either of an 
active or passive character. 

Among the moral causes of insanity, or those in which there is an 
overaction of the mind, producing the cephalic inflammation and nervous 
irritability, are severe study, perplexing investigations, political or reli- 
gious excitement, fits of anger, remorse, erotic exuberance, connubial 
disturbance, fear, despair, loss of friends, abuse of confidence, public 



INSANITY. 



293 



disgrace, violated chastity, destitution, and finally, the witnessing or 
hearing of executions, murders, suicides, &c. 

Any physical cause capable of producing either an active or passive 
inflammation of the brain or its meninges, directly or by sympathy, may 
be an exciting cause of insanity. But the most frequent causes thus 
operating, are direct injuries, protracted watchings, irregular eating, 
masturbation, onanism and sexual excesses, the use of tobacco, drunken- 
ness, licentiousness, &c. Of these causes, the use of tobacco, masturba- 
tion, protracted drunkenness, and licentiousness, together with depressing 
moral causes, tend to produce dementia, while those causes calculated to 
excite a particular passion, as ambition, revenge, &c, tend to develop 
monomania. 

Of the other causes which I have enumerated, both physical and 
moral, some tend to produce or develop one form of insanity and others 
another, according to the nature and extent of the inflammation which 
they set up in the brain and its meninges, as well as the general dis- 
turbance they produce in the nervous system generally. 

The puerperal state has been supposed to predispose to, or act as a 
cause of insanity. And it is not strange that it should, when we remem- 
ber the great change the female system undergoes from the period of 
conception to the termination of lactation, especially if we take into 
account the unnatural and imprudent sexual indulgences which are too 
often resorted to in this delicate state of the female constitution. 

Pathology. — I have already anticipated much in relation to the nature 
or pathology of insanity, so that but little remains to be said. I will therefore 
only arrange and give a synopsis of my views of the pathology of insan- 
ity, and dismiss this branch of our subject. 

It is my opinion, that the mind comes directly from God, " who is the 
Father of our spirits," that it possesses properties, powers and faculties 
of its own, and that it is capable of thinking, acting, and reasoning within 
itself, independent of the body, by its own God-given powers. And 
further, that it is immaterial or spirit, and not like the physical organiza- 
tion liable to disease. That the body is not a necessary appendage of 
the mind, but a mere instrument, which in our present degenerate state, 
serves only for a limited period of time. And finally, that the mind 
being a spirit is immortal and will exist after the death and decomposi- 
tion of our bodies, and that it is liable only to moral disease. 

Now if this be true, we have a rational solution of all the phenomena 
of every variety of insanity. For as the body is the instrument of the 
mind, and the nervous system including the brain, the medium through 
which the mind receives and transmits its impressions or ideas, any de- 
rangement of the brain and nervous system, sufficient to hinder a correct 
communication of impressions through the senses to the mind, or from 
the mind through the brain and nerves to other minds is what we call 
insanity. 

Now we know that impressions from without are received through the 
senses, being transmitted along the nerves, spinal cord, and white tubular 
matter of the brain, to the gray matter of the hemispheres, and through 
this gray or cortical matter directly to the mind itself. Conversely 
when the mind sends forth impressions or ideas, it passes them directly 



294 DISEASES OF THE NERVOUS SYSTEM. 

to the gray matter of the hemispheres, and thence along the white tubular 
matter of the brain, spinal cord, and nerves, to the voluntary muscles 
designed to be called into action, whether for locomotion or for the com- 
munication of ideas to other minds, through the organs of speech, the 
cerebellum harmonizing these motions. Now so long as this channel or 
medium of communication, between the mind at one extreme, and the 
material world and other minds at the other extreme remains perfect, 
impressions are communicated in a correct and rational manner; but 
when it is more or less interrupted we have the different varieties of 
insanity, varying from the slightest mania to utter idiocy. 

If the derangement in this medium of communication consists in active 
irritation, or inflammation of the gray matter of the brain, or its men- 
inges, involving the brain, we have that variety of interruption to the 
communication of ideas, which we call mania. 

If we have temporary congestion and irritation of the brain from over 
action of the mind upon some particular theme, whenever the mind calls 
up that theme, and a remission when the mind is called off on other sub- 
jects, we have that variety of interruption to the communication of ideas, 
which constitutes monomania. 

But if we have a debilitated condition of the nervous system, with 
irritation, and perhaps passive inflammation of the brain, or its men- 
inges, we have that derangement in the communicating medium, which 
allows the transmission of a multitude of ideas, but in so imperfect, dis- 
connected a manner, as to constitute dementia. 

Again, when by long abuse of the system the organs of sense have 
become so much deranged as to communicate, for a long time, false im- 
pressions to the mind, the mind so situated fails to acquire correct notions 
of its obligations, and hence becomes reckless of those principles of order 
or morality which should guide all rational intelligent beings, thus con- 
stituting moral insanity. 

Finally, when from inherited congenital, or acquired imperfection of 
this medium of communication, there is an entire incapacity for the 
transmission of ideas, even in the most imperfect manner, utter idiotism 
is the result. 

Thus we have, in my view, the true pathology of insanity : a deranged 
condition of the nervous system being an invariable condition, while de- 
bility, irritation, congestion, or an active or passive inflammation of the 
brain, and especially of the gray matter of the hemispheres is a general, 
if not an invariable morbid condition in every variety, except perhaps in 
moral insanity. 

Diagnosis. — The diagnosis of insanity is not in general attended with 
any considerable difficulty, if the history and symptoms of the case be 
carefully learned, and all the extrinsic circumstances be taken into 
account. In ordinary acute and chronic meningitis there is generally 
sufficient irritation, or inflammation of the cortical or gray matter of the 
brain to interrupt, for the time, the correct communication of impressions 
or ideas, developing symptoms of mania, or dementia, according to the 
nature or extent of the cephalic inflammation. 

The same is also true in the delirium of fever, and in delirium tremens, 
though the irritation in such cases of the nervous system may be from 



INSANITY. 295 

passive inflammation, or mere debility of the brain, as is evidently the 
case in the latter affection. So, too, a wicked profligate course of life, 
from a willful and malicious disposition, may develop symptoms similar 
to moral insanity, though not identical with it, as in such cases the 
injuries are apt to be inflicted upon real enemies, while in moral insanity 
they may fall upon intimate friends, and without the least provocation. 

So, too, common eccentricity of character may simulate, in many res- 
pects, monomania; but it differs in this, that such peculiarities are apt 
to be more or less congenital, while monomania is generally acquired 
from a worriment or over-action of the mind upon the subject of the in- 
sanity. Finally, it may be an important point to decide upon the insanity 
of a patient in doubtful cases, for legal purposes, to establish the validity 
of wills, or to guide in the trial and decision of cases in which there is 
the charge of capital or other high crimes. 

Now, it is my opinion that every condition of a patient whether it be 
the result of acute or chronic meningitis, or of inflammation, irritation, 
or debility of the brain arising during fever, or any other general condi- 
tion of the system, whether temporary or permanent, should be regarded 
and treated legally as insanity so long as the brain and nervous system 
generally are not in a condition to transmit or receive impressions or 
ideas in a correct or rational manner. 

And finally, that all those cases of gross immorality in which capital 
or other crimes are committed upon friends, without any provocation, or 
any real or imaginary cause, should be regarded as moral insanity, and 
that such persons should be subjected to proper restraint. But that such 
a state should be legally no palliation for crimes actually committed any 
more than drunkenness is, which is really a temporary moral insanity. 

Prognosis. — The prognosis in insanity varies with the hereditary pre- 
disposition, and also the nature and extent of the physical derangement, 
as well as the duration of the disease. In patients in which there is a 
strong hereditary predisposition to insanity, if the disease be developed 
early in life, it may often be arrested for a time ; but it is exceedingly 
liable to return, sooner or later, and at last to become permanent. 

In cases of insanity from accidental causes, and not hereditary, if 
proper treatment be resorted to early, the cause having been removed, 
I believe reasonable hopes may be entertained of a recovery in most 
cases. Among the cases of insanity that have fallen under my observa- 
tion and care, most have recovered, if the cause has been early removed, 
and the patient properly treated, before a chronic state had supervened. 
But among cases that have fallen under my care, in which there was a 
strong hereditary predisposition, and the patient advanced in life, I have 
had one most deplorable fatal case, and another in which there was only 
a partial recovery. Excepting these two cases, I have generally suc- 
ceeded, sooner or later, in my cases of insanity, if I except also cases of 
moral insanity, in which I have generally failed. 

Finally, from all the observations that I have been able to make on 
this subject, I believe that nearly or quite nine-tenths of all the cases 
of insanity not strongly hereditary, that receive proper treatment during 
the early stage of the disease, may reasonably be expected to recover. 
In this estimate, however, I do not include cases of moral insanity 



296 DISEASES OF THE NERVOUS SYSTEM. 

and idiocy; the former of which, under proper moral, and the latter 
under proper physical and moral treatment, may possibly improve ; but 
I seriously doubt if a perfect, permanent recovery is often effected in 
such cases. 

Treatment. — In the treatment of insanity the cause should be sought 
out, and if possible removed, whether it be physical or moral; after 
which, the patient should be treated on strictly rational principles, 
physical and moral. The patient should be placed in a situation either 
at home or in some approved institution for the insane, where, without 
unreasonable restraint there will be a reasonable security that he will in- 
flict no injury upon himself or any one else. 

Every cause of physical or mental excitement should be carefully re- 
moved and the patient kept cleanly, allowed good air, and should have 
his food served up with regularity and of a character exactly suited to 
his condition. These preliminaries having been arranged, if any over- 
action of the mind from worriment, excitement, or any other mental ex- 
cess is found to have been operating to produce the derangement of the 
physical organization, that source of worriment or excitement should be 
carefully avoided, and the mind drawn off, as much as may be, upon 
other subjects suited to his state. 

If the physical derangement has been produced by any imprudence, 
such as masturbation, onanism, sexual excesses, the use of tobacco, 
drunkenness, licentiousness, or any other varieties of imprudence, they 
should be prohibited, and the patient made to conform rigidly to the 
laws of health and propriety. When all this has been carefully and 
prudently done, the exact deviation from the standard of health of the 
physical organization should be ascertained, and then the indications 
fullfiled in every respect, and the treatment persevered in till the physi- 
cal derangement is corrected, at which time the brain and nervous sys- 
tem will resume their function of communicating impressions or ideas to 
and from the mind, in a correct or rational manner. 

If there be acute or chronic inflammation of the brain, a cathartic of 
calomel or podophyllin may be indicated at first, and later, a pill of 
aloes and rhubarb, two grains of aloes and one grain of rhubarb may be 
given at evening each day, to secure a regular action of the bowels, and 
to lessen the determination to the brain. Cups, wet or dry, to the temples 
or back of the neck occasionally at first, and later, blisters or pustula- 
tion with tartar emetic ointment are generally indicated, to be varied of 
course, according to the nature and extent of the cephalic inflammation. 
The warm foot-bath should be used at evening for a time, and the head 
kept elevated, and if nothing contra-indicate, it may be showered each 
morning with cold water. 

With this course of treatment, the inflammation of the brain or its 
meninges may generally be subdued, if resorted to in season, and thus 
in a reasonable time the insanity may disappear. At least such has 
been the result of my observation in such cases. 

If, however, the cephalic inflammation be of a passive character, the 
result of a debilitated anaemic condition of the system, the drastic 
cathartics should be omitted, and only dry cups, blisters, &c, applied to 
the temples, back of the neck, or back of the ears. 



INSANITY. 



297 



The warm foot-bath may be used, as well as moderately cool water to 
the head by showering in the morning. And besides the pill of aloes 
and rhubarb at evening, or after dinner each day, some preparation 
of iron should be administered and continued after each meal till a 
healthy state of the blood is restored. If only the simple tonic effects 
of iron are indicated, the citrate in solution, or the iron by hydrogen 
in powder three times per day may do best. If there be a dropsical 
tendency, ten or twelve drops of the tincture of muriate of iron is a 
preferable form, to be administered in a little water. But if there be 
a scrofulous tendency, the syrup of the iodide of iron, administered in a 
little water before each meal will generally do best. 

Such, according to my view, are the general indications in the treat- 
ment of the inflammation of the brain or its meninges, which is so apt 
to be a condition in almost every variety of insanity. If other portions 
of the system be in a healthy state, little treatment further than I have 
suggested may be required. But if the cephalic inflammation be symp- 
tomatic of, or complicated with disease of other organs, as the liver, 
alimentary canal, kidneys or genital organs, such disease should, if pos- 
sible, be subdued, and the general health and tone of the system re- 
stored. 

If the liver or kidneys are in a torpid inactive state, alteratives or 
diuretics may be indicated, and should be resorted to in conjunction 
with the other treatment. If there is indigestion with debility of the 
stomach, or irritation of the alimentary mucous membrane, antacids, 
tonics, and perhaps counter-irritants may be required. Finally, if the 
patient be a female, and the insanity has supervened upon suppression 
of the menses, or any menstrual irregularity, a healthy state of that 
function should be restored by such remedies as appear to be indicated 
in the case. 

Such I believe are the principles which should guide us in the treat- 
ment of all ordinary cases of insanity. But cases may occur in which 
only proper air, exercise, and diet, with perhaps tonics, is all that may 
be required. This, in fact, may often be the case in puerperal cases, as 
I have succeeded with a moderate dose of blue pill, followed by castor- 
oil, and the subsequent use of moderate doses of the sulphate of quinine, 
continued for a few days. 

In cases of moral insanity, I believe that the general health and tone 
of the system should, if possible, be restored, by judicious medical treat- 
ment, and then the patient brought under the most approved moral and 
religious influence. "Religion," says Hufeland,* "is the best thing in 
man ; it is that which constitutes him such an one ; it is the essential 
part of his life ; therefore it is religion, when all other means fail, that 
the patient's thoughts and actions must be referred to. On this account, 
going to church and conversation with a sensible clergymen is advised." 

Now I can give no better advice in cases of moral insanity, after re- 
storing the health and tone of the physical organization, than to repeat 
the suggestions quoted above from one of the noblest minds that ever 
graced the medical or any other profession. And now, in conclusion, I 



* See Hufeland's Enchiridion Medicum, p. 202. 



298 DISEASES OF THE NERVOUS SYSTEM. 

will only suggest, that in cases of partial idiocy, if any treatment be 
attempted, it should be of a physical and moral character, and such as 
is adapted to each particular case. 

SECTION XIV.— MANIA A POTIJ— [Delirium Tremens.) 

By delirium tremens, or mania a potu, I mean that peculiar affection 
of the nervous system, the result, generally, of the use of alcoholic 
liquors, opium, or tobacco, and characterized by muscular tremors, want 
of sleep, and delirious hallucinations. It occurs in habitual drunkards, 
and in such as are addicted to the use of opium ; and it also occurs, oc- 
casionally, from the excessive use of tobacco. 

Now, by the long continued use of these poisons, the system becomes 
accustomed to their stimulating effects, the various functions of the body 
become deranged, and the tone, strength and vigor of the brain and 
whole nervous system become impaired, in consequence of their debili- 
tating effects. In consequence of the debility thus produced, the stimu- 
lus has to be gradually increased, in order to keep up the impression, 
and while this is done, no delirium ordinarily occurs. But if, in conse- 
quence of sickness, an injuriy, or from any other cause, the accustomed 
stimulus be removed, or suspended, or even greatly diminished, the sys- 
tem sinks down, or appears as it really is. The nerves become unstrung 
and the brain irritable, in consequence of which muscular tremors, wake- 
fulness and delirium, with all the symptoms of this affection, make their 
appearance. While, then, delirium tremens is thus the result of the debili- 
tating effects of alcoholic drinks, opium and tobacco, the delirium and 
other symptoms of the disease do not ordinarily make their appearance 
till the system is allowed by their suspension to feel its real condition, 
by a removal of the intoxication. 

Symptoms. — On the removal of the intoxicating agent, whether it be 
alcohol, opium or tobacco, there is generally exhibited more or less lassi- 
tude and general indisposition. There is a feeling of distress in the epi- 
gastrium, nausea and vomiting, giddiness, confusion in the head, want 
of sleep, and an anxious expression of the countenance, with tremor of 
the hands. 

After these premonitory symptoms have continued for a day or two, 
the patient exhibits symptoms of suspicion and alarm, the eyes are fixed 
upon some real or imaginary object, or cast about with rapid scrutinizing 
glances, the patient becomes restless and irritable, he walks to and fro 
by day, and is unable to sleep during the night. The tremor increases, 
and the patient becomes loquacious and more or less deranged, and 
though he may claim to feel well, he is apt to be tormented with various 
disgusting, alarming and ludicrous imaginary appearances. He imagines 
that he sees dogs, snakes, cats, mice, and various other animals in his 
room; and lice, bugs, or other disgusting vermin crawling over his bed, 
and on his clothes ; or that various persons of a fearful character and 
appearance have entered his room for the purpose of robbing or killing 
him. 

In one case that fell under my care a few years since, the man, at 
home, supposed himself among strangers, and surrounded by what he 



MANIA A POTU. 299 

called a host of "land-pirates," and he appeared to be in constant and 
most terrible fear of becoming a victim to their cruelty. His wife, he 
supposed, was his land-lady, and he indulged in many curious specula- 
tions in relation to her hospitality, as well as her good looks; and he 
appeared to hope that possibly she might befriend him. But still he had 
constant suspicion as to her character, and a constant unconquerable 
dread of the host of "land-pirates," by which he imagined himself sur- 
rounded and fearfully beset. 

Patients, to avoid such and other horrible allusions, will often call 
loudly for assistanae, and becoming greatly agitated, will often threaten, 
and sometimes rave violently. The mind and body are in a continued 
state of action. They will walk hurriedly about the room, or run to the 
window and call to some imaginary person in the street, or start suddenly 
with horror, terror, and agitation, from the presence of frightful and 
disgusting apparitions, and insist perhaps that they are well and confined 
unjustly, and that they should be permitted to attend to some important 
and pressing business transaction. 

In most cases that have fallen under my observation, if the patient be 
not too plainly contradicted, or too sternly opposed, they have been con- 
trolled without any very coercive measures ; but in some cases, when the 
disease rises to a higher grade of violence, the patient becomes furiously 
delirious, and being unable to recognize even his nearest relatives and 
friends is restrained with difficulty. 

One severe case of delirium tremens that fell under my observation a 
few years since, exhibited most of these symptoms. In this case, the 
patient was so annoyed by imaginary, disgusting, and fearful objects that 
he emptied the straw from his bed into the street, and set it on fire to 
get rid of his fearful intruders, all the time brushing them from his per- 
son and trying to prevent their escape from the flames, which, however, 
he found not very effectual, especially in destroying several small and 
very saucy looking evil spirits, or " little devils" as he called them, 
which he thought "bore the fire very well." 

He insisted that his head was covered with lice and various kinds of 
bugs, and fearful insects, and so certain was he of this, that he procured 
a tub of water, and placing himself over it, he labored for hours to detach 
them by means of his hands, combs, brushes, &c, and at the same time 
defending himself against the serpents, evil spirits, and numerous other 
fearful imaginary enemies, which he represented as acting in the most 
saucy, impudent, and provoking manner, and aiming all their spite, 
venom, and impudent tricks at him. This case exhibited various other 
symptoms, which I need not mention, but recovered after having been 
delirious for about one week. According to my observation, persons suffer- 
ing from delirium tremens do not appear to be susceptible to much bodily 
pain, or even to suffer much from bodily injuries, so long as the delirium 
continues. 

The pulse in this disease varies in different cases, being sometimes 
hard, full and frequent, but generally soft, full, and quick, without much 
strength, or any considerable tension. The skin is generally moist and 
cool, the tongue covered with a white fur, the bowels torpid and along 
with slight thirst for cool drinks, there is a disinclination to take food, 
during the whole course of the disease. 



300 DISEASES OF THE NERVOUS SYSTEM. 

The duration and degree of violence of this affection vary in different 
cases, sometimes only slight tremor of the hands, with transient deli- 
rium, sensorial illusions and wakefulness, continue for two or three days, 
and then pass off. 

In other cases the wakefulness, tremor of the hands, general restless- 
ness and agitation continue for five or six days, with delirium and annoy- 
ing apparitions at night, while during the day, the patient remains 
tolerably quiet. But in severe cases, the symptoms continue day and 
night, with but slight remissions, for one or two weeks, or even longer, 
if not arrested by proper treatment. If the disease be left to itself, or 
maltreated there is danger of protracted or even permanent insanity. 

Diagnosis. — The diagnosis of this disease is not generally attended 
with any considerable difficulty, if ail the symptoms, as well as the ex- 
trinsic circumstances be carefully taken into account. From the dilirium 
of fever, from meningitis, and from ordinary insanity, this disease may 
be distinguished by the following differences. 

From the delirium of fever it differs in wanting the general febrile 
symptoms, in its fantastic hallucinations, and in the general tremor, fear, 
and constant apprehensions of various real or imaginary objects. From 
meningitis it differs in wanting the local and general inflammatory symp- 
toms, by the want of convulsions and coma, and by the imaginary and 
fearful apparitions and muscular tremors in this disease. From ordinary 
insanity this disease differs by being generally more rapid in its ap- 
proach ; by the patient being more constantly tormented by apprehen- 
sions of danger, and finally in the fact that delirium tremens is either 
the direct or indirect result of alcohol, opium or tobacco, while ordinary 
insanity may be produced by various other causes. 

Anatomical Characters. — No appearances are presented on the post- 
mortem examination of patients dead of this disease, which account for 
the symptoms which are developed. In some cases, more or less serum 
has been found in the cavity of the arachnoid, in the ventricles of the 
brain, and infiltrated into the cerebral substance, and also signs of 
inflammation of the brain or its meninges ; all of which, however, appear 
to be the result of accidental complications, as they are entirely wanting 
in other cases. 

Various other accidental appearances are occasionally presented in 
different parts of the body, the most frequent of which appear to be 
signs of pneumonia, pleurisy, gastritis, enteritis, and inflammation, fatty 
degeneration, &c, of the liver or kidneys ; the result generally of the 
intemperance which has led to the disease, but not an invariable morbid 
condition in this disease. 

Causes. — Alcoholic drinks are probably the most frequent cause of 
delirium tremens, while opium and tobacco are occasional causes. 

Alcohol being a stimulant and irritant, without containing any material 
nutritious properties, its long continued use creates an irritation of the 
mucous membrane of the stomach; which being transmitted by the 
sympathetic and pneumogastric nerves to the brain, produces a tem- 
porary stimulation, but a permanent debilitating effect upon the brain 
and the whole nervous system. It is probable also that a portion of the 
alcohol enters the circulation, and so passes directly to the brain, pro- 
ducing its temporary irritating and permanent debilitating effects. Now 






MANIA A POTU. 301 

as the tone and strength of the brain and whole nervous system become 
gradually lowered ; more of the alcoholic stimulant is required to keep 
up sufficient intoxication, to prevent the individual from knowing or 
feeling the real debility which is being produced, and this is why drunk- 
ards increase the quantity of liquor each succeeding year. 

If now, in such a case, from any cause, the alcoholic irritant be with- 
held, the removal of the irritant and its intoxicating effects allows the 
system to sink down to its real condition, very much in the same 
manner that a person irritated and intoxicated, by anger, gradually 
assumes his real state of mind and strength of body, after the fit of anger 
passes off. iSiow, as the system in such a case assumes its real level, 
the brain and whole nervous system which have long been accustomed to 
this irritated condition, become completely unstrung, and thus the symp- 
toms which follow. 

The brain and nervous system are no longer in a condition to transmit 
impressions to or from the mind. As a consequence of this, every im- 
pression received through the organs of sense, many of which are imagi- 
nary, coming to the mind through this shattered and unstrung nervous 
system, is converted into an object of terror, which keeps the mind in 
constant dread of their annoyance ; while, on the other hand, the com- 
mands of the will, or impressions from the mind sent forth upon the 
brain and nerves to the voluntary muscles are very imperfectly commu- 
nicated, whether for locomotion or for articulate sounds or speech, hence 
the insanity in this disease. 

Finally, as the brain is debilitated in such a state, sufficient nervous 
influence is not generated and distributed to the nerves to keep them in 
proper tone, and hence the muscular tremors which occur in this distress- 
ing affection. 

Opium, we have seen, is a cause of delirium tremens, and though it 
does not so markedly irritate the mucous membrane of the stomach, it 
deranges the secretion of the liver and more or less of the whole glandu- 
lar system and produces the same temporary stimulating and permanent 
debilitating effects as are produced by alcohol. After its continued and 
protracted use the brain and nervous system become so accustomed to its 
impressions that its removal produces the same train of symptoms which 
are developed in the affection when produced by alcohol, and for the 
same reasons. 

Tobacco is an occasional cause of delirium tremens; and it is not 
strange, when we remember that it contains nicotin, nicotianina, and an 
empyreumatic oil ; all of which are most virulent and deadly poisons. 
Its long continued use, either by chewing, snuffing or smoking, so far 
poisons the blood and debilitates the brain and whole nervous system, 
that when from any cause it is suddenly withdrawn and the intoxication 
which it produces passes off, the patient becomes conscious of his real con- 
dition, and the brain and whole nervous system being unstrung and ex- 
cessively irritable, tremor, wakefulness, delirium and all the symptoms 
of delirium tremens from the effects of alcohol is liable to be the result. 

It is possible that tobacco may produce this disease by its direct de- 
bilitating effects while the system is under its influence, but according to 
my observation, the horror, wakefulness, muscular tremors and delirium 



302 DISEASES OF THE NERVOUS SYSTEM. 

occur when, from a removal of the drug, its intoxicating effects have 
passed off, and the patient feels his real debility. 

Pathology. — From what we have already seen, the pathology of this 
disease may readily be inferred. That it depends entirely upon the de- 
bilitating effects of alcohol, opium, or tobacco, upon the general system, 
and especially upon the brain and nervous system, generally, it appears 
to me, that there is no reasonable room for doubt, when their direct or indi- 
rect effects are taken into account. That the sudden removal of these 
debilitating poisonous irritants and their attendant intoxication should so 
far let down the system to its real condition that the brain and whole 
nervous system should be so irritable, weak and tremulous or debilitated 
as to develop all the symptoms which arise, is not at all strange, and 
that, too, without producing, necessarily, any congestion or inflammation 
of the brain or any other tissue of the body. 

Delirium tremens then consists, esentiaily, in a weakened, debilitated 
and irritable condition of the general system, and essentially of the 
brain and whole nervous system ; in consequence of which, the brain is 
unable to generate and supply to the nerves a sufficient amount of vital 
nervous power to enable them, with the brain, to act correctly as the 
organ of the mind, or to enable the various organs of the body to per- 
form with due regularity their accustomed functions ; hence the tremor, 
wakefulness, delirium, &c, which occur in this disease. 

Prognosis. — The prognosis in delirium tremens, so far as the recovery 
from an attack is concerned, may be regarded as generally favorable, 
unless the patient dies from exhaustion, or passive congestion, or inflam- 
mation supervene. But when we take into account the terrible condition 
of the system which develops this affection, and its causes, and that 
almost the only hope of a permanent relief of the horror which attends 
such a condition, is to be found in the poison which has produced it, or 
a kindred one, the prognosis so far as the ultimate result of the case is 
concerned, is always unfavorable. 

Treatment. — The indications of treatment are plainly to keep the 
patient under proper restraint, to stimulate to a condition compatible 
with rest, and quiet the brain and nervous system, to afford a due amount 
of proper nourishment, and, finally, to leave the patient in the most 
favorable condition possible for the permanent abandonment of the ruin- 
ous habit which has led to the disease, whether it be from the use of 
alcohol, opium or tobacco. 

I believe sufficient restraint should be exercised over the patient to 
prevent him from injuring himself or others, but that further than this 
should never be attempted, as it generally tends to increase the irritabi- 
lity, according to my observation. In mild cases of this affection, whether 
it be the result of liquor, opium, or tobacco, an attempt should be made 
to arrest the disease, without resorting to the poison which has been the 
cause of it. After having arranged the preliminaries in relation to pro- 
per restraint, the patient should not be too abruptly opposed or disputed 
in relation to his imaginary dangers, and should be persuaded to take 
either a strong infusion of the tincture, or else the fluid extract of vale- 
rian or hops. Of these, two or three fluid drachms of the tincture, or 
one cr two of the fluid extract of either, may be given every three or 



MANIA A POTU. 303 

four hours at first, and later every six hours, while the restlessness and 
tremor continue; the patient being persuaded, if possible, to take a little 
milk in crust water, or some other mild digestible and nourishing food. 

If symptoms of passive congestion of the brain supervene, the warm 
foot-bath may be resorted to, and dry cups applied to the back of the 
neck, but this I think will very rarely be necessary. With this mild 
course of treatment, some cases may recover in a few days, and if they 
do, due caution should be taken to prevent the patient from returning to 
the ruinous habit of drinking, opium eating, or tobacco using, which may 
have been the cause of the disease. 

In more severe cases, or in mild cases in which this mild course fails 
to arrest the disease, five grains of Dover's powder, with three grains of 
the James's powder, may be combined, and given every four or six 
hours. Or if the antimonial be contra-indicated, thirty or forty drops 
of the tincture or fluid extract of opium may be given every four or six 
hours, instead of the antimonial and Dover's powder, and continued till 
rest, quiet and sleep are procured. If, however, as sometimes happens, 
this plan of treatment also fails, good brandy should be given in wine 
glassfull doses every six hours, and alternating with it one or two 
fluid drachms of the tincture of asafetida, and continued till rest, quiet 
and sleep is procured, when the brandy should be withheld, but the 
asafetida continued till the disease and its effects have passed off, when 
that should be gradually discontinued also. 

The patient should be allowed crust coffee, one-half milk at first, and 
later, a poached egg, toast, and other varieties of plain, digestible and 
nourishing food, to be taken at regular meal hours ; and after the dis- 
ease has passed off, and as the stimulants are discontinued, moderate 
doses of an infusion of columbo, or twenty or thirty drops of the fluid 
extract may be given after each meal, and continued for a time, to im- 
prove the appetite and favor digestion. 

In those cases of delirium tremens produced by opium or tobacco, the 
same course of treatment should be pursued, and the patient cured, if 
possible, without a resort to the poison which has produced the disease. 
If, however, it becomes necessary to resort to the opium or tobacco 
temporarily, they should be discontinued gradually, as the delirium 
passes off, and finally abandoned altogether. If opium has been the 
cause, it may thus be abandoned permanently, as is the case with alco- 
holic drinks ; but to abandon tobacco is generally, according to my 
observation, attended with more difficulty. 

There is, however, at this hour, a respectable gentleman of this village 
in my office, who suffered with all the essential symptoms of delirium 
tremens twelve years ago, from the use of tobacco, and who, having 
abandoned its use, since that time is in the enjoyment of tolerable 
health, though he assures me that his system has not entirely rallied 
from its pernicious effects. 

In those cases of delirium which occasionally occur during the con- 
tinued use of alcohol, opium or tobacco, which have some of the symp- 
toms of delirium tremens, I believe the symptoms are from inflamma- 
tion of an active or passive character of the brain or its meninges, and 
the disease not strictly delirium tremens. 



304 DISEASES OF THE NERVOUS SYSTEM. 

SECTION XV.— ECLAMPSIA.— ( Convulsions.) 

By eclampsia, or convulsions, I mean here that condition of the 
nervous system, but especially of the Brain and spinal cord, in which, 
without constituting an essential part of any recognized disease, there 
are clonic spasms of the muscles with irregular motions of the limbs and 
various parts of the body, and attended generally with temporary uncon- 
sciousness. 

Now this condition being the result of accidental causes, acting 
directly upon the brain or else upon other parts, as the alimentary 
canal, and affecting the brain sympathetically, is liable to occur at any 
period of life. But as the head of children is larger in proportion to 
the rest of the body than in the adult, and as the brain is probably 
softer ; accidental convulsions are much more liable to occur in infants 
or children than in adults. 

These accidental convulsions, however, are not necessarily confined to 
infancy or even childhood, but they may occur at any age from various 
causes and conditions ; and especially in females during pregnancy, or in 
the puerperal state. Accidental convulsions may be preceded by slight 
indisposition, or they may come on suddenly, without any special 
warning of their approach. 

Symptoms. — Accidental convulsions are most liable to occur in chil- 
dren or adults of unusually large heads and short necks, other things 
being equal. The spasms may effect all the voluntary muscles, more or 
less, or they may be of one half of the body or even of a single part, 
as a limb or the muscles of the face, as I have known in some cases. 
In some cases there is only a single attack, lasting from five to fifteen 
minutes, while in other cases there may be several following in more or 
less rapid succession, depending in some degree upon the nature and 
permanency of the accidental cause, and also the means made use of to 
arrest them. 

If the convulsions depend upon irritation of the brain, with vascular 
congestion, the face will often appear swelled and the face and lips livid, 
or of a bluish appearance, the jugulars will be distended, the surface hot, 
and the pulse frequent, but often very irregular ; but if, as is sometimes 
the case, the convulsions are the result of nervous irritation with depres- 
sion, the face may be pale, and want that swelled or congested appear- 
ance, the skin may be cool and the pulse though frequent, is generally 
feebler than in health, according to my observation at least. 

During the continuance of the convulsions, which may last only for a 
few minutes, or in other cases, occurring at irregular intervals for several 
days, or even longer, the abdomen is apt to be tympanitic, involuntary evac- 
uations may occur, and as an attack of the convulsions subsides, there is 
a comatose tendency, the patient being more or less disposed to sleep for 
a time, in most cases. In cases, however, in which the convulsions have 
been produced by irritation and depression, without much, if any, con- 
gestion of the brain, the patient especially if an infant, appears quite 
natural, immediately after the cessation of an attack of convulsions. 

Accidental convulsions are not generally attended with any very con- 
siderable danger, but there occurs sometimes serious cerebral or spinal lesion, 



ECLAMPSIA. 305 

leaving strabismus, local paralysis, or perhaps some serious mental dis- 
turbance, or death may occur from an interruption of a due innervation 
of the heart or lungs, or perhaps from other causes. In cases of death 
occurring thus in accidental convulsions, the post-mortem may reveal 
nothing to account for the sad result, but generally there are found signs 
of congestion or inflammation of the brain or spinal marrow, or else 
tumors, effusions or softening, which may account for the convulsions at 
least, and generally for the fatal termination. 

Causes. — A large head and a short neck, with an irritable condition 
of the nervous system, and especially of the brain and spinal cord, 
strongly predisposes to convulsion, in both infants and adults. And 
while accidental convulsions may occur from various exciting causes in 
any one, it should be remembered that with this physical peculiarity, it 
may occur from slight causes, such as in the other cases might produce 
little or no perceptible disturbance. 

The causes most liable to produce convulsions either directly or indi- 
rectly in adults are imprudence in eating and drinking, the use of tobacco, 
excessive venery, fear, excessive anger, direct injuries, protracted grief, 
and finally, pregnancy or the puerperal state. Of these causes, some 
may act by producing direct irritation, and either an active or passive 
congestion of the brain or spinal cord, while others may act by affecting 
the brain or spine sympathetically, while others still, may act either 
mechanically, or else by producing an anaemic condition, and conse- 
quently an irritability of the brain, and whole nervous system. 

The frequency of convulsions during pregnancy or in the puerperal 
state, may be accounted for in part I think, from the changes which the 
system undergoes from the period of conception to the close of lactation. 
These changes rendering the whole nervous system more or less irritable, 
especially if, as is too often the case, sexual intercourse be indulged in, 
with various other imprudences. It is possible also that convulsions may 
be produced during the latter months of pregnancy, from the slight 
mechanical obstructions to the free passage of blood along the abdomi- 
nal vessels, especially in anaemic debilitated females. Convulsions may 
also occur immediately after the delivery or during labor, and in many 
cases I am satisfied from worriment and general nervous irritability. 
Convulsions in infants may be the result of imprudence on the part of 
the mother, such as taking improper food, indulging in fits of anger, 
allowing the infant to nurse at irregular, unseasonable hours, or of feed- 
ing young infants unnecessarily with various kinds of solid food, and 
other like imprudences. 

During childhood, various causes may operate to produce accidental 
convulsions, such as dentition, direct injuries, intestinal worms, &c, but 
none, according to my observation so frequent, as the indigestion, irritation, 
and derangement of the system, brought about by irregular eating, or 
taking food between meals. This habit is sure sooner or later to destroy 
or impair the natural appetite, and to create instead, a morbid one, so 
that the child may eat little at one meal, and far too much at another, 
and as indigestion with gastro-intestinal irritation is sure to be set up, and 
as a consequence, more or less cerebro-spinal irritation, occasional convul- 
sions are very apt to occur. 
20 



306 DISEASES OF THE NERVOUS SYSTEM. 

The direct cause of the convulsions in such cases, may be active con- 
gestion of the brain and spinal cord, or it may be from passive conges- 
tion from the debility which the indigestion produces in such cases, or it 
may be from the irritability of the cerebro-spinal, and whole nervous 
system, which according to my observation is an invariable result of pro- 
tracted irregular eating, or taking of food between meals. Now I am 
Satisfied, from careful observation, that a large majority of the acciden- 
tal convulsions occurring in children, and generally supposed to be the 
effects of intestinal worms, are really the result of irregular eating, the 
gastro-intestinal irritation, together with the debility, which it produces, 
causing sufficient cerebro-spinal and general nervous derangement, to 
produce the convulsions which occur. 

Diagnosis. — It may be difficult, in many cases, to decide whether con- 
vulsions are the result of some accidental cause, or whether they may 
not be the commencement of some specific disease, as hysteria, epilepsy, 
&c. If, however, the habits of the patient, as well as all the circum- 
stances connected with the attack, be carefully taken into account, a 
probable diagnosis may be formed between purely accidental cases and 
those which are to attend some permanent specific disease. 

Practically, it is of vital importance to ascertain the direct and remote 
cause of the convulsions. The direct cause, that proper treatment may 
be had during the convulsons ; and the remote cause, that it may if pos- 
sible be removed, and thus a return of the convulsions be prevented. If 
the convulsions be the result of active congestion of the brain and spinal 
cord, the face is generally flushed, the pulse strong, and the heat of the 
surface above a healthy standard. But if the convulsions be the result 
of passive congestion, or of general nervous irritation from debility, the 
face may be pale ; the pulse is more feeble than in health, and on the 
subsidence of the spasms there is not generally so marked comatose 
symptoms as occur in cases from active congestion. 

Prognosis. — In those cases of accidental convulsions in which there is 
no considerable hereditary predisposition to cephalic congestion, or 
cerebro-spinal irritation, the prognosis is generally favorable, if the 
cause which is operating can be ascertained and removed. But in cases 
in which there is a strong inherited predisposition, or in which convul- 
sions are produced by very slight causes, serious apprehensions may rea- 
sonably be had as to their final result. Cases of this character may ter- 
minate fatally, during a fit of convulsions ; or some serious cephalic or 
nervous affection may follow, as the result of the repeated cerebro-spinal 
congestions. 

Treatment. — The treatment of accidental convulsions consists in that 
which is proper during a convulsive attack, and that which may be ne- 
cessary during the intervals, to prevent a return of the spasmodic 
affection. 

During an attack of convulsions, if it be from active cerebro-spinal 
congestion, the patient, whether an adult or an infant, should be placed 
with the head elevated, and the feet in warm water; should be allowed 
fresh air ; and if there is much heat and dryness of the skin, and the 
head is hot, cloths wet in cool water may be applied to the head. Imme- 
diately on removing the feet from the warm water, they should be wrap- 






ECLAMPSIA. 307 

ped up, and kept warm, and sinapisms not too stimulating should be ap- 
plied and continued to the bottom of the feet, while the cephalic tend- 
ency continues. 

If the patient be plethoric, and the convulsions are obstinate, blood 
may be taken from the arm, or cups or leeches applied to the temples, or 
back of the neck. And if symptoms of cerebro-spinal inflammation 
continue after the convulsions subside, a cathartic of calomel, or 
podoplryllin may be administered, and followed, if necessary, by a full 
dose of the sulphate of magnesia, and blisters applied back of the ears, 
or to the back of the neck ; and all the indications fulfilled, till the in- 
flammation is subdued. 

In cases of convulsions from passive congestion, the warm foot bath 
may be used, and an infusion of capsicum along the spine, as well as sina- 
pisms to the feet, or extremities ; but general bleeding should not be 
resorted to, or even wet cupping, as a general rule. But if symptoms of 
passive inflammation continue after the convulsions subside, mild cathar- 
tics, such as the blue pill, or a pill of aloes and rhubarb maybe indicated, 
as well as blisters back of the ears, or to the back of the neck ; and thus 
the inflammation may be subdued. 

In cases of convulsions from debility, with irritation of the whole 
nervous system ; but especially of the brain, and spinal cord, such as are 
liable to occur during labor, or after delivery ; in cases in which there is 
no inflammation, or even active congestion ; every cause of irritation 
should be removed, and along with sinapisms to the extremities, elevation 
of the head, and fresh air, the tincture of asafetida, with the infusion, 
ammoniated tincture, or fluid extract of valerian may be administered, to 
diminish nervous irritability and to promote a proper distribution of the 
nervous influence ; upon the derangement of which, the convulsions in 
such cases probably depend. To prevent a return of each paroxysm ; 
cloths wet in cold water, should be applied suddenly to the face and neck, 
the shock of which, I believe may generally arrest them, as it did in one 
puerperal case that fell under my care. Such I believe is the most safe 
and convenient method of fulfilling the indications, during the spasms, 
in the various forms of accidental convulsive affections. 

Now, immediately on the subsidence of the convulsions, the remote 
cause should be sought out, if possible, and removed ; and the condition 
of the system, which is the immediate cause of the convulsions corrected, 
so far as it may be. If the patient be an infant, and the cause irregular 
nursing, or improper feeding, the imprudence should be corrected. If 
the convulsions arise from the irritation of dentition, the gums may be 
carefully cut, and thus that source of irritation removed. If intestinal 
worms be the cause, a full dose of calomel may be administered, at first, 
in castor oil ; and if necessary, small doses of the oil of turpentine ad- 
ministered at meal hours, for two or three weeks, or some other vermifuge 
given, if that be contra-indicated. 

If indigestion and gastro-intestinal irritation, from irregular eating, 
or taking food between meals be the cause, the child or adult, whoever 
it may be, should be allowed a reasonable amount of plain, digestible, 
and nourishing food at regular meal hours, but not one morsel between 
meals. If, with the indigestion there be a diarrhoea and acidity of the 



308 DISEASES OF THE NERVOUS SYSTEM. 

stomach, small doses of the compound tincture of rhubarb with a little 
prepared chalk, taken after each meal, may be sufficient to correct the 
difficulty. 

If the indigestion be attended with constipation, and the patient 
be an infant or a very young child, a drachm each, of the sulphate of 
magnesia, and rhubarb should be added to half a pint of water, and a 
teaspoonful given each morning, and if necessary, at evening, till the 
constipation is corrected. If the patient be an adult, a pill of aloes and 
rhubarb, of each a grain and a half, may be given after dinner each day, 
and continued till the constipation is overcome. 

If the use of tobacco, masturbation, onanism, or excessive venery, 
be the cause of the convulsions, the imprudence should be corrected, and 
the patient made to conform rigidly to the laws of health and propriety. 
After having corrected the imprudence, if the anaemic debilitated state, 
in such cases require a tonic, the citrate, carbonate or ferrocyanuret of 
iron should be administered in moderate doses, till the strength of the 
blood and the tone of the nervous system are restored. 

In puerperal cases, every possible cause of irritation should be re- 
moved, as well as imprudence corrected, and along with a regulated diet, 
good air, and a reasonable amount of exercise, absolute freedom from 
worriment should be enjoined. Such I believe are the principles which 
should guide us in the treatment and prevention of the various forms of 
accidental convulsions. 

SECTION XVI.— HYSTERIA. 

By hysteria, from the Greek So-tzpa, "uterus," I mean that peculiar affec- 
tion of the nervous system, characterized by uterine or other primary 
local irritations and more or less sympathetic irritation and congestion 
of some portion of the spinal cord or brain, with irregular distribution 
of the nervous influence, and in some cases convulsions. 

When the primary uterine or other local irritation ft not very consider- 
able, and the sympathetic irritation of the brain or spinal cord is quite gene- 
ral, and there is no special local point of irritation along the spine, or 
in the brain, the hysteria, according to my observation, generally develops 
itself in a slow and irregular manner, constituting chronic hysteria. 
When, however, the primary uterine or other local irritation is consider- 
able, and the sympathetic irritation of the brain and spinal cord is very 
decided, and especially of the superior portion of the spinal cord, with 
more or less active congestion of these parts, the disease generally de- 
velops itself in paroxysms of convulsive hysteria. 

Finally, when the primary uterine, gastric, or other irritation is very 
great, and the sympathetic irritation of the cerebro-spinal system falls 
mainly upon the brain, producing at times severe cephalic congestion, 
the hysteric paroxysm is often characterized by coma, insensibility, or 
stupor. Hence, we have three prominent modifications, or varieties 
of hysteria, depending, according to my observation, upon the degree 
and extent of the primary uterine, gastric, or other irritations, and also 
upon the nature, seat, and degree of the cerebro-spinal irritation and 
congestion. Let us now proceed to examine the symptoms of the differ- 
ent modifications of hysteria, and first of the chronic. 



HYSTERIA. 309 

Symptoms. — Chronic hysteria, as we have seen, is that variety in 
which the sympathetic irritation affects the cerebro-spinal and ganglionic 
systems without fixing especially upon any particular part of the brain 
or spinal cord, in consequence of which, the patient is almost constantly 
afflicted with various hysteric symptoms, without suffering from any 
very severe paroxysms. The symptoms of chronic hysteria are just 
what might be expected from such a condition of the nervous system. 
The temper is variable, the patient being sometimes animated, and at 
others peevish and gloomy. The patient may pass rapidly from laugh- 
ing to crying ; from gaiety to melancholy ; from despondency to hope ; 
and all for the most trifling causes. 

The sympathetic irritability of the cerebro-spinal and ganglionic 
systems develops often various distressing sensations in the head, chest, 
abdomen and pelvis, such as a sense of weight or bearing-down in the 
region of the uterus; flatulency, colic, pains or rumbling in the bowels; 
a feeling of emptiness or tension in the pit of the stomach ; variable ap- 
petite, slow digestion, eructations, &c. ; palpitations, weakness and 
syncope ; ringing in the ears ; confusion of the mind and pains in various 
parts of the body, and finally, the "globus hystericus," or the sensation 
of a ball rising in the throat to the top of the sternum, causing oppressed 
and hurried respiration, and often a feeling of impending suffocation. 

Such, according to my observation, are the usual symptoms of chronic 
hysteria; and the changeable character of the symptoms, or the rapid 
change of location of the morbid symptoms, depends, I believe, upon the 
general sympathetic irritation of the nervous system. The slight local 
irritation of the brain or spinal cord, changing from one point to another, 
develops the symptoms which arise in the head, chest, abdomen, pelvis 
and other parts. 

Paroxysmal or convulsive hysteria is developed, as we have seen, in 
consequence of sympathetic irritation of the cerebro-spinal system, and 
especially of the superior portion of the spinal cord ; the congestion which 
attends producing the paroxysms of convulsive hysteria. Now, if this 
idea be correct, the symptoms which are developed in convulsive hysteria 
are just what might be expected. 

Various premonitory symptoms may occur, such as a very lively or else 
an opposite, sullen, or gloomy mood ; but generally, I think the paroxysms 
come on quite suddenly. Sometimes the fit consists in violent and con- 
vulsive laughing, alternating with crying and screaming, or there is rapid 
and incoherent talking, singing, suffocative spasms of the throat; a wild 
and furious expression of the countenance; raving; gnashing of the 
teeth ; tearing out the hair ; biting ; beating the breast with the hand, &c. 
Sometimes these symptoms subside without the congestion or disturbance 
of the nervous influence being sufficient to develop convulsions; but gene- 
rally, in such cases, convulsions of considerable violence speedily 
supervene. 

The spasms, when they occur, usually partake of the tonic character, 
the body being rigidly bent backwards, or variously contorted; the 
breast is projected forward and the head drawn backward; the face is 
swelled; the tongue is either protruded or the jaws firmly closed; the 
eyes are rolling, prominent, and red; the fists are clenched; the arms 



810 DISEASES OF THE NERVOUS SYSTEM. 

may be spasmodically thrown about ; the abdominal muscles contracted, 
and the whole muscular system is often thrown into such violent spasms 
that it is sometimes very difficult to keep the patient on the bed. When 
the paroxysm ceases, the patient is sometimes left in a stupid or somno- 
lent state, which passes off in an hour or two, very much like the somno- 
lency of epilepsy. 

This modification of hysteria does not usually occur in weak or debili- 
tated patients, as is the case with the chronic variety, but more fre- 
quently in sanguineous, plethoric, and robust females of strong passions, 
and occurs, usually, according to my observation, in consequence of some 
disagreeable mental emotion, or from a sudden suppression of the menses. 
In some cases of this variety of hysteric convulsions, the heart and 
arteries appear to be prominently affected; the heart palpitates violently, 
the pulse beats tumultuously, the carotids throb, the face becomes 
flushed and turgid, there is headache, with slight delirium, and a more 
or less hurried and anxious respiration. 

When the point of local sympathetic irritation is in that portion of the 
spinal cord which supplies, most directly, nerves for the respiratory 
organs, the hysteric paroxysm may assume the character of violent 
asthma. I have known the spasm of the larynx so great, in such cases, 
that the patient would appear to be suffocating, when the spasms would 
yield, and the patient would again revive. Such, according to my ob- 
servation, are the symptoms of the acute, convulsive, hysteric paroxysm. 
The symptoms of that modification of hysteria which is developed in 
consequence of a sympathetic irritation affecting the cerebro-spinal sys- 
tem, and producing a congestion of the brain, are very similar to those 
of apoplexy, and for similar reasons. In this modification of hysteria 
there may be slight premonitory symptoms, but the patient usually, with- 
out any considerable spasms, sinks into a state of insensibility. The 
patient in such a state generally lies on the back, with the limbs relaxed, 
and perhaps extended; the eyes are closed; the breathing is slow and 
laborious, but scarcely audible; the pulse is slow; the countenance pale ; 
the extremities cold, and generally the power of swallowing is lost, and 
the sensorial functions for the time appear suspended. Occasionally, 
while the patient lies in this state, a long inspiration is made, and I 
have known patients, as partial sensibility returns, to tear their clothes 
from the bosom, or to press upon it with both hands firmly. 

The duration of this variety of hysteric paroxysm may vary from a 
few minutes to several hours, and I have known patients to remain in 
this state for a whole day, and then rather suddenly to awake, as from a 
deep sleep. As the patient thus awakes, I have seen them raise up to a 
sitting posture, and look around, apparently with surprise, and very soon 
recoyer the entire possession of their corporeal and mental powers. This 
variety of the hysteric paroxysm may occur from various causes, but I 
have most frequently noticed it in young females, from suppression of 
the menses. 

Anatomical Characters. — The post-mortem examination of hysteric 
patients, that have died of some acute disease, reveals no morbid lesions 
which appear at all connected with the hysterical affection. This nega- 
tive testimony, together with the fact that patients seldom or never die 



HYSTERIA. dll 

of pure hysteria, is sufficient evidence of the purely functional character 
of this disease. 

Causes. — Any inherited or acquired undue excitability of the nervous 
system predisposes to hysteria. Girls of a delicate habit of body, with 
precocious intellects, an animated disposition, and an early sexual de- 
velopment, are generally most predisposed to hysterical affections. In 
such females, slight causes may produce gastric, uterine, or some other 
local primary irritation, and then either general or local irritation of a 
sympathetic character is set up in the nervous system, involving the 
spinal cord, and perhaps /the brain, and thus some form of hysteria is 
developed. 

I believe the most frequent exciting causes of hysteria are constipation 
of the bowels, suppression of the menses, and the frequent excitation of 
voluptuous feelings, by improper reading, conversation, and the working 
of an unchaste and too active imagination. 

Pathology. — In relation to the nature of hysteria, but little more than 
I have already suggested need be said. The disease occurs almost ex- 
clusively in females ; and generally between the commencement, and final 
cessation of the uterine functions, which is a strong argument in favor of 
the uterus, as the seat of primary irritation in this disease. It is proba- 
ble, however, that other parts, as the alimentary canal, may be the seat 
of primary irritation, or derangement in hysteria. 

It is probable that there is generally a primary local irritation of the 
womb or alimentary canal, or some other part ; from which a sympathetic 
irritation is communicated to some portion of the spinal cord, or brain, 
through the ganglionic and cerebro-spinal nerves. If, as we have seen, 
there is no special point of irritation along the spine, or in the brain — 
we have the symptoms of what I have called chronic hysteria. If there 
be some special point of sympathetic irritation along the superior part of 
the spine — we have the hysteric convulsions. But if the sympathetic 
irritation, and congestion involve the brain, as well as the spinal cord, we 
may have hysteric insensibility. 

Now it is probable, that the direct cause of the symptoms which are 
developed in every form of hysteria, is a derangement in the generation, 
or bad distribution of the nervous influence ; in consequence of which 
more or less of the functions of the body are either deranged, or tem- 
porarily suspended, during the hysterical condition. 

It will be seen that I have supposed both a primary and sympathetic 
irritation in every form of hysteria ; and I believe that such is generally 
the case. But it is probable that an anaemic condition, with excessive 
nervous irritability, involving the cerebro-spinal, and ganglionic system 
of nerves ; as well as the brain and spinal cord may lead to sufficient de- 
rangement in the generation, and distribution of the nervous influence, 
to develop the different forms of hysteria, without any special primary, or 
sympathetic local irritation, acting as a cause. If now my views of the 
pathology, or nature of hysteria be correct — we have a solution of all the 
symptoms which are developed in every possible modification of the 
disease. 

Diagnosis. — Hysteria may generally be distinguished by careful ob- 
servation of all the symptoms ; especially if the character, history, and 



312 DISEASES OF THE NERVOUS SYSTEM. 

general condition of the patient be taken into the account. The only 
disease with which it is very liable to be confounded, is epilepsy ; from 
which it differs in several essential particulars. 

The hysteric paroxysm wants the "aura epileptica," the sudden cry at 
the seizure of the fit ; the distortion of the features ; the foaming at the 
mouth ; and finally the deep coma which attends, and follows the epilep- 
tic paroxysm. Besides, hysteria has the alternate laughing and crying ; 
the "globus hystericus," and the healthy expression of countenance 
between the paroxysms, which is not common in epilepsy. 

The functional derangements which occur in the different organs of the 
body in hysteria, and which are apt to simulate inflammatory, and other 
serious or troublesome affections, may generally be distinguished from 
those diseases, by a careful observation of all the symptoms in the case. 

Prognosis. — The prognosis in hysteria, so far as a fatal termination is 
concerned, may be regarded as favorable. But hysteria is an affection, 
which, if once fully developed, is very liable to continue, or to return, at 
least, at intervals for many years ; often till after the cessation of the 
menstrual function, even though it commence with the first dawning of 
menstruation. 

Treatment. — During a paroxysm of hysteria the patient should be 
placed in as convenient and comfortable a position as may be, and 
should be kept from injuring herself, or any one else, with as little 
absolute restraint as may be sufficient for that end. The feet should be 
placed in warm water, if necessary, and the head kept elevated and 
moderately cool, and, if the cephalic congestion be very considerable, a 
few ounces of blood should be taken from the back of the neck by cups. 
Or if some point in the spine appears to be the seat of the greatest sym- 
pathetic irritation and congestion, cups should be applied on each side 
of the spine, at the point of greatest irritation and congestion. 

Sinapisms should be applied to the epigastrium, and to the lower 
extremities, and a brisk irritation produced. In this way the hysteric 
paroxysm may generally be overcome, after which the cause should be 
sought out and removed, as far as may be, and the treatment should be 
directed to the removal of the primary local irritation, whether in the 
uterus or elsewhere, and thus an effort made to correct the general 
nervous irritability, which generally exists in such cases. 

Having inquired into the remote cause, as well as the general habits 
of the patient, every imprudence should be corrected, and the patient 
made to conform, rigidly, to the laws of health and propriety. In this 
way alone may the source of the primary irritation be cut off, and toler- 
able hope of its removal be entertained. Having arranged these essen- 
tial preliminaries, attention should be directed to the removal of the 
primary local irritation. 

If constipation of the bowels be the cause, the diet should be of a 
nature calculated to overcome that difficulty, as far as may be, and a pill 
of aloes and rhubarb be given after dinner, each day ; or, if there be 
hepatic derangement, a drachm of the fluid extract, or a wineglassful of 
the infusion of taraxicum, made from two ounces of the dandelion root to 
a pint of boiling water, may be given after each meal, and continued till 
the hepatic secretion is restored, and the constipation overcome. 



SPINAL IRRITATION. 313 

If suppression of the menses appears to be the cause, a full dose of the 
sulphate of magnesia, or calomel and castor oil, should be given at first, 
and then a pill, of equal parts of aloes and rhubarb, should be directed 
after dinner, each day, till the bowels are regulated. After regulating 
the diet, and correcting the constipation, if there be heat, pain, or un- 
easiness in the region of the womb, cups may be applied to the sacrum, 
occasionally, and at the period when the menses should appear; the 
warm foot-bath should be used at evening, and sinapisms applied to the 
sacrum, on retiring to bed at night. If the menses do not appear from 
this course of treatment, Dewee's Tincture of guaiac should be given, in 
teaspoonful doses, after each meal ; and if the patient be ansemic, ten 
drops of the syrup of the iodide of iron, or else tincture of the chloride, 
should be given before each meal, and this treatment continued till the 
menses are restored, when the hysteric symptoms will generally subside. 

In chronic hysteria and all other varieties occurring in girls or young 
women, and not dependent upon constipation or suppression of the 
menses, the cause which is keeping up the primary, sympathetic, or 
general nervous irritability, should be ascertained, and removed if possi- 
ble. If there be uterine irritation from any imprudence, without men- 
strual irregularities, the imprudence should be corrected, and its conse- 
quences explained to the patient, as well as the local uterine irritation 
subdued by dry cups to the sacrum, and injections of cool water into the 
vagina, if necessary. 

In hysteria occurring in anaemic females about the time of their final 
cessation of the menses, a gentle tonic course is often indicated. A pill 
of two grains of the ferrocyanuret of iron, with one-fourth or one-half a 
grain of aloes, I have found of very essential service, given after each 
meal, and continued for a reasonable time. 

In all cases of hysteria in which it becomes necessary to arrest spas- 
modic actions, and at the same time to allay nervous irritability, ten 
drops each of the tincture of stramonium, tincture of opium, and sul- 
phuric ether, may be administered, every six hours, till the spasms and 
excessive nervous irritability are subdued. In hysteria occurring in de- 
bilitated females, attended with irregular spasms, a teaspoonful of the 
tincture of asafetida, or a pill of three or four grains of the gum, may 
be given every four or six hours, and continued till the spasms are 
subdued. 

A regulated diet, regular habits, and an even temper of mind should 
be enjoined in all females suffering from hysteria, or who are predisposed 
to this affection. By attending thus rigidly to the laws of health and 
propriety, and doing just so much by way of medicines as is indicated 
and necessary, and nothing more ; most nervous hysterical patients may 
be greatly benefitted, and many permanently cured. 

SECTION XVII.— SPINAL IRRITATION. 

By spinal irritation I mean here that variety of spinal affection in 
which there is more or less tenderness, on pressure, upon the spinous 
processes along some portion of the spine. 

Symptoms. — Spinal irritation is generally attended with more or less 



314 DISEASES OF THE NERVOUS SYSTEM. 

numbness, stiffness, slight pain, and more or less acute tenderness of that 
portion of the spine involved in the irritation. But the most prominent 
symptoms of this affection are remote from the spine, at the extremity 
of, or along the course of the nerves proceeding from that portion of the 
spine involved in the irritation. 

If the irritation be in the superior portion of the spine, there is often 
pain, spasms, and a distressing cough, from derangement in the nerves 
of the larynx. If the irritation be a little lower in the cervical portion 
of the spine, the brachial plexus of nerves becomes involved, so that there 
is often numbness, pain, or perhaps partial paralysis of one or both arms, 
and palpitation of the heart ; asthma ; and perhaps sufficient irritation or 
derangement produced in the pulmonary nerves to produce a most dis- 
tressing spasmodic cough. 

If the irritation be in the dorsal region of the spine, there is apt to be 
pains along the intercostal muscles, in the region of the spleen, stomach 
and liver, and very often functional derangement of the stomach, liver, 
kidneys, and alimentary canal. Among the functional derangements of 
the abdominal viscera which I have noticed, from spinal irritation, are 
nausea, vomiting, constipation of the bowels, a torpid state of the liver, 
spasm of the bile duct, and a tympanitic state of the abdomen. If the 
spinal irritation be along the lower portion of the dorsal, or in the lum- 
bar or sacral region, there may be neuralgia or functional derangement 
of the kidneys, bladder, rectum, womb, testicles, and of the lower ex- 
tremities ; all of which parts I have repeatedly found more or less de- 
ranged from spinal irritation. 

Now the patients may suffer some pain and uneasiness in the spine at 
the point of irritation, but more generally the pain or functional derange- 
ment is complained of along the course of the nerves supplied by the 
irritated portion of the spine, or at their extremities. The patient, how- 
ever, may suffer acute pain in the spine if they sit back against a chair, 
or if firm pressure be made along the spinous processes, and generally 
the pain or derangement along the course of the nerves, or at their ex- 
tremity, is increased by this pressure if firmly made. 

In cases in which the irritation is in the superior portion of the spine, 
involving the nerves of the respiratory organs or heart, if firm pressure 
be made it will often produce cough or palpitation or both. If there be 
neuralgia of one or both arms, pressure will often increase the pain, and 
the same is true of other neuralgic or functional derangements of the 
abdominal and pelvic viscera, as well as of the lower extremities. 

Diagnosis. — There is little difficulty in distinguishing spinal irritation 
as there is always tenderness on pressure, if firmly made along the 
spinous processes of the affected part. This will always enable the care- 
ful observer to distinguish spinal irritation, proper, from transient neu- 
ralgic spinal pains which are generally sympathetic of irritation in other 
parts, as of the womb, testicles, bladder, kidneys, alimentary canal, &c. 
Causes. — I am satisfied, from careful observation, that in most cases of 
spinal irritation in which there is tenderness on pressure, that some 
direct injury, such as wrenching, overlifting, falls, bruises, and other 
accidents, is generally the cause of the slow irritation which is set up. 
It is probable, however, that some cases in which there is tenderness on 



TETANUS. 315 

pressure, are the result of sympathetic irritation, from some remote dis- 
ease in the stomach, liver, intestines, kidneys, womb, bladder, or other 
parts. 

"When such local irritation of the spine exists, it is increased or aggra- 
vated by very many causes, such as concussions, lifting, a low electrical 
state of the atmosphere, mental excitement, and various other causes, 
which alone might not be sufficient to produce spinal tenderness if it did 
not already exist. 

Nature. — I believe that spinal irritation, with tenderness, consists in 
a chronic inflammation of the spinal ligaments, of either a simple or 
rheumatic character; the irritation, if not the inflammation, extending 
more or less to the spinal cord or its meninges, and involving the roots 
of the spinal nerves, as well as their envelope derived from the membranes 
of the cord. It is probable that in severe protracted cases there is con- 
gestion or chronic thickening of the ligaments of the vertebrae, of the 
spinal membranes, and probably of the origin of the nervous envelopes 
or neurilemma, which disturbs, by the pressure which is made upon the 
spinal cord and its nerves, more or less, the flow of nervous influence, 
not only along the cord, but also along the nerves to the muscles and 
other parts which they supply ; and hence the neuralgia, and functional 
derangements which we have seen so often occur. 

Prognosis. — The prognosis, so far as a serious result is concerned, is 
generally favorable, as most cases improve from proper treatment. But 
according to my observation, it is very liable to return, from various im- 
prudences, after it has been materially improved, or even apparently 
cured, by a proper course of treatment. 

Treatment. — To arrive at the indications of treatment of spinal irri- 
tation, it is necessary to ascertain whether it is entirely the result of some 
local injury of the part; or whether it may not have been produced, or great- 
ly increased, sympathetically, by some organic, or other disease of the 
thoracic, abdominal, or pelvic viscera. If then the disease be sympathetic, 
or if it originated in injury of the spine, and has produced important 
sympathetic derangement of the different organs, or functions of the 
body ; the first indications are to correct, as far as may be these deranged 
organs, or their functions, and then to subdue, if possible, the spinal irri- 
tation, if any remains. If the patient be of a strong vigorous constitu- 
tion, a little blood may be taken by cups on each side of the spine, at the 
irritated point. But if the patient be anaemic, dry cups only should be 
applied for a few times ; and then blisters, tartar emetic pustulation, or 
issuse may be made use of, and continued till the irritation is subdued. 

SECTION XVIII.— TETANUS— {Locked Jaiv.) 

By tetanus, from izivu "I stretch," I mean that peculiar deranged con- 
dition of the nervous system; especially of the superior portion of the 
spinal cord, including the medulla oblongata ; attended with tonic spasm 
of the voluntary muscles, without coma, or any essential disturbance of 
sensation, or of the mental faculties. This affection differs from many 
of the convulsive affections, in there being generally no sensorial, and 
intellectual derangement. This, however, is not an invariable rule ; for 



316 DISEASES OF THE NERVOUS SYSTEM. 

I have seen cases in which there was more or less mental disturbance 
from the first. 

That variety of tetanus which affects the muscles of the throat and 
jaws, has been called trismus ; when the extensor muscles of the trunk, 
and lower extremities are mainly implicated, the body being bent violently 
backward, it is called opisthotonos ; when the body is curved forward, >t 
is termed emprosthotonos ; and finally, when it is curved laterally, it is 
called pleurosthotonos ; all, however, being mere modifications of the same 
disease. 

Tetanus has been again divided into idiopathic and symptomatic : the 
idiopathic including all cases which arise, without any other known disease 
condition ; while the symptomatic is the result of some previous affection, 
involving generally, more or less, the nervous system. Cases of the 
symptomatic variety, which originate in wounds, or direct injuries, have 
been denominated traumatic tetanus. 

This division, however, is of little consequence, as the real condition 
is the same in all, and the division into traumatic, including all cases the 
result of wounds or direct injuries ; and idiopathic, including all other 
cases, may be sufficiently definite for our present purpose ; as it appears 
to be the division more generally understood. 

Tetanus generally approaches gradually, so that several days may 
elapse between the first manifestation of its invasion, and its complete 
development. Sometimes, however, its approach is rapid, its symptoms 
being fully developed in a few hours after the injury of which it is symp- 
tomatic is received. 

Symptoms. — The most common early symptoms of tetanus, are stiffness 
of the back of the neck, spasmodic sensations in the muscles of the 
larynx, by which the voice is slightly changed, difficulty in swallowing, 
rigidity of the jaws, with pain in opening the mouth, and an uneasiness 
in the epigastrium, with pains darting from the pit of the stomach towards 
the spine. Soon the muscles of the neck and jaws become more stiff, the 
ja-ws being firmly closed. Deglutition is now performed with pain, and 
is apt to produce spasm. As the disease advances, the pain and retrac- 
tion, with the darting pains, return at the epigastrium every ten or fifteen 
minutes, in violent paroxysms ; and are generally followed by spasmodic 
retraction of the head, and soon by a rigid contraction of nearly all the 
voluntary muscles of the body. 

There is a permanent spasm of the muscles, bnt as these paroxysms 
return, the muscles of the throat and chest are painfully contracted, the 
arms and legs may be forcibly extended, the shoulders drawn forward, 
the abdominal muscles retracted against the viscera, and the whole body 
thrown into a most painful and unyielding tonic spasm. These paroxysms 
at the commencement usually last but a few minutes, but in the latter 
period of the disease, the spasms remit but slightly, the muscular con- 
tractions being general and extremely violent. 

During the progress of the disease, the countenance becomes distorted, 
copious sweats break out, the pulse becomes quick and irregular, the 
jaws immoveably fixed, the respiration laborious, the sphincters rigidly 
contracted ; and towards a fatal termination, slight delirium occurs, and 
finally, a severe spasm terminates the scene, or the muscles become re- 
laxed, and the patient dies in an apparent apoplectic state. 



TETANUS. 317 

The voluntary muscles supplied by the spinal nerves are the ones first 
affected, but before a fatal termination, the involuntary muscles, con- 
trolled more especially by the ganglionic nerves may become affected, 
and thus by interrupting the involuntary functions, as the circulation, 
respiration, &c, be the cause of death. In some cases, the mind con- 
tinues clear to the last, but in most cases that have fallen under my 
observation, there has been more or less mental disturbance during some 
period of the disease. 

Tetanus may terminate fatally by the fifth or sixth day, or recovery 
may take place in a week or less. But the disease often continues for 
several weeks, and thus assumes a chronic form ; and even after recovery 
there is apt to be a degree of stiffness of the muscles, and nervous irrita- 
bility for several months. 

Trismus nascentium or that variety of tetanus which occurs in infants 
soon after birth, supposed by some to arise from the irritation of cutting 
the cord ; by others, from displacement of the occipital bone, but proba- 
bly the result of filth, exposure, and various other imprudences, is of an 
alarming fatal character, calling loudly for cleanliness, fresh air, and a 
proper management of infants, as prophylactic measures against the 
disease. The disease occurs most frequently in hot climates, being very 
destructive in the West Indies, and among certain classes, especially the 
blacks in some of our Southern States. The attack generally occurs 
during the first or second week after birth, the disease being attended 
with spasmodic closure of the jaws, and the various other tetanic symp- 
toms. 

Anatomical Characters. — In some fatal cases of tetanus no traces of dis- 
ease have been found, while in others, signs of congestion, or sanguineous 
injection of the cerebro-spinal meninges, and of the roots of the spinal 
nerves have been discovered, and sometimes increased vascularity of the 
brain and spinal cord, with or without serous effusion into the cavities. 
Blood has been found within the spinal sheath, and in some cases evi- 
dences of inflammation of the meninges of the brain or spine, and also 
softening of the brain or spinal marrow. 

In traumatic cases, the nerves involved in the wound have been found 
variously lacerated, thickened, softened, &c. And the cervical and 
semilunar ganglia are sometimes more or less injected. Various other 
appearances are occasionally presented, such as tubercles, cerebral 
abscesses, or cartilaginous or bony formations in some portion of the 
spinal meninges, &c. 

Diagnosis. — The only diseases with which tetanus is liable to be con- 
founded, are hydrophobia, and convulsive hysteria, from both of which it 
may be readily distinguished by careful attention to all the symptoms. 
The symptoms of tetanus, including the permanent tonic spasm of the 
voluntary muscles, with paroxysms of greater violence, the peculiar pain 
at the epigastrium, the expression of the countenance, together with the 
absence of coma or marked delirium, will always enable the careful 
observer to distinguish tetanus from hysteria, hydrophobia, and in fact 
all other affections. It is of the greatest importance, however, to dis- 
tinguish between inflammatory and non-inflammatory cases of tetanus, in 
arriving at the indications in the treatment, which may generally be 



318 DISEASES OF THE NERVOUS SYSTEM. 

done by noticing carefully any symptoms of cerebro-spinal inflammation 
which may arise, whether of the cerebro-spinal substance or their me- 
ninges. 

Causes. — There appears to be a hereditary predisposition to tetanus 
in some constitutions, but in what that predisposition consists is not 
quite certain. I believe that exposure to filth, bad air, and various 
other imprudencies, which render the nervous system irritable, also pre- 
dispose to this affection, as we have seen in the infantile cases occurring 
among the blacks in some portions of our Southern States. 

It is probable, also, that males are more predisposed to tetanus than 
females, and that other things being equal, the disease is more liable to 
occur in hot climates than in temperate or cold climates, and, finally, 
that while the disease may occur at any age, it is vastly more liable to 
occur in the young and middle aged than in advanced life. 

The exciting causes may act generally upon the nervous system, as 
sudden extremes of temperature, fear, &c, producing the idiopathic 
variety, or they may act locally, as wounds, bruises, &c, producing the 
traumatic. Of local injuries, those which bruise or injure a nerve, ap- 
pear most liable to produce tetanus, especially if the wound has partially 
divided a nerve, or is of a punctured character. 

In one successful case of traumatic tetanus which fell under my care, 
the injury was from the thorn of a plum tree, which penerated the heel. 
In another case which fell under my observation, the injury was of the 
nerves in the palm of the hand, produced by pressing it too firmly 
against the point of a heavy weight, which the patient had been lifting. 
This case was treated successfully by my friend and former partner and 
preceptor, Dr. Win. V. Y. Rose, of Watertown, 1ST. Y. In traumatic 
cases, the interval between the reception of the injury and the occurrence 
of the tetanic symptoms may vary from a few minutes to two or three 
weeks, but I think it seldom occurs later than that. 

Pathology. — Whether tetanus be the result of a general or local cause, 
irritation, congestion, or inflammation of the spinal cord, including the 
medulla oblongata, or of the spinal and perhaps cerebral meninges, 
invariably exist to a greater or less degree and extent in every case ; 
and in some cases probably the white tubular, and perhaps even the gray 
matter of the brain become more or less involved. Now the degree and 
extent of this irritation, congestion, or inflammation of the spinal cord 
and brain, as well as of the cerebro-spinal meninges, makes the differ- 
ences which occur in different cases of tetanus, as well as the differences 
which occur in different stages of the same case. 

If there be only irritation with slight congestion of the spinal cord or 
its meninges, the tetanic symptoms are often mild and the case may 
terminate favorably. But if the spinal cord or its meninges becomes 
severely irritated, congested or inflamed, the tetanic symptoms are 
usually more severe, and the violent paroxysms of spasms more frequent, 
only slight remissions occurring early, while in the latter stages the 
violent spasm becomes continuous. In those cases in which the spinal 
irritation, congestion or inflammation extends either early, or during the 
latter stages of the disease, to the substance of the brain, there may be 
coma and more or less mental disturbance, especially if the gray matter 



TETANUS. 319 

of the brain becomes implicated ; and the patient may die either from 
the involuntary muscles becoming involved, from exhaustion, or else in an 
apoplectic state. 

Now in every case, whether there be only irritation of the spinal cord, 
or irritation, congestion, inflammation, &c, there is an interruption to, 
or derangement in the flow of nervous influence along the spinal cord and 
its nerves ; in consequence of which the voluntary muscles are thrown 
into spasms. If, however, the brain itself becomes seriously involved, 
the power to act, or supply of nervous influence to the ganglionic system 
is interrupted or cut off, and hence the suspension of the vital functions 
and speedy dissolution which follows in such cases. 

Prognosis. — The prognosis in tetanus is generally unfavorable, and 
especially is this the case in traumatic cases. In many cases of idio- 
pathic tetanus, a recovery may reasonably be expected if the patient 
receive proper treatment, and with the same favorable circumstances, 
some traumatic cases may recover, at least such has been the result of 
my observation. The favorable symptoms are, mildness of the attack, 
relaxation between the paroxysms, and a tolerable performance of the 
respiratory and circulatory functions ; while the unfavorable symptoms 
are the opposite of the above, and an evidence of an extension of the 
spasms to the involuntary muscles, indicated by a derangement in or 
interruption of more or less of the involuntary functions, as of the 
respiration, circulation, &c. 

Treatment. — As tetanus is a disease in which the spine or its meninges 
are always either irritated, congested or inflamed, the indications to be 
fulfilled are usually very plain. In mild cases of traumatic or idiopathic 
tetanus, there may be only irritation with perhaps slight congestion of 
either an active or passive character, depending upon the general con- 
dition of the system at the time of attack. In cases of this character if 
it be the result of local injury, warm soothing fomentations or poultices 
should be applied to the wound, and suppuration promoted as far as 
possible. In addition to this in traumatic cases, and in mild idiopathic 
cases, the feet should if possible be placed in warm water, and a cathar- 
tic of the sulphate of magnesia, podophyllin or colomel in castor oil, 
should be administered and a free operation secured. 

After the operation of a cathartic five grains of Dover's powder may 
be given, every four or six hours, and if the patient is weak, ansemic, or 
debilitated, three or four grains of the sulphate of quinine may be given 
with each Dover's powder, for the purpose of equalizing the circulation, 
and overcoming the cerebro-spinal congestion and irritation. If, how- 
ever, the patient is of a strong and vigorous constitution, and the spinal 
congestion is of an active character, instead of the quinine, three or four 
grains of the James's powder may be given with the Dover's, and dry 
cups applied along each side of the spine, and thus the spinal congestion 
and irritation be overcome, as far as may be. 

Thus I believe the indications may be fulfilled, in mild traumatic or 
idiopathic tetanus, in which there is only irritation with slight conges- 
tion of the spinal cord, active medication in such cases, in my opinion, 
aggravating rather than palliating the disease. But in severe cases of 
tetanus, whether traumatic or idiopathic, there may be not only irrita- 



320 DISEASES OF THE NERVOUS SYSTEM. 

tion and congestion, but there may be a high state of inflammation of 
the spinal marrow, or its meninges, so that the case demands early and 
more active treatment, as it tends rapidly to a fatal termination — the 
inflammation extending to the brain or its meninges. 

In such cases, after dividing the wounded nerves, if necessary, apply- 
ing poultices to the wounds, &c, if the tetanus be traumatic ; general 
bleeding should be resorted to, if the patient is strong, or of a full ple- 
thoric habit. After general bleeding, when it is indicated, and in all 
such cases in which general bleeding is not necessary, cups should be 
applied to each side of the spine, along its whole length, and from three 
to six ounces of blood taken at first. A cathartic of calomel and castor 
oil should be given, and its operation secured by repeated doses of oil, if 
necessary ; or if calomel be contraindicated, a full dose of podophyllin, 
or senna, may be given, and followed by the sulphate of magnesia, if 
necessary. 

After the operation of a cathartic, sixty drops of laudanum, or ten 
drops of the fluid extract of the cannabis indica, may be given every 
four hours ; and with each dose of laudanum, or of the hemp, from one- 
fourth to half a grain of tartar emetic may be given. Alternating with 
the anodyne, two or three grains of calomel may be given, and con- 
tinued till slight ptyalism is produced. 

After the bleeding, cupping, and operation of a cathartic, if the 
tetanic symptoms continue unabated, vesication should be produced 
along each side of the spine, its whole length, either with a strong solu- 
tion of corrosive sublimate, Granvill's lotion, or a solution of caustic 
potash, one drachm to an ounce of water. This solution of potash is the 
most convenient, in such cases, if it happens to be at hand ; and it may 
be applied with a sponge, drawn quickly along each side of the spine, 
from the neck to the sacrum. 

If the cupping and vesication be resorted to early, in these inflamma- 
tory cases of tetanus, before any effusion or other serious organic change 
occurs, the tetanic symptoms may subside, and the patient recover. It 
is well in such cases, after the tetanic symptoms subside, to give, for a 
week or two, five grains of the iodide of potassium, three times per day, 
to prevent any effusion into the cerebro-spinal arachnoid cavity, or into 
the ventricles of the brain ; as there may be a tendency to such a result. 

The patient should be sustained by a reasonable amount of proper 
nourishment, such as toast water, or crust coffee with milk, toast, rice, 
&c. ; and if the powers of the system sink in this disease, broths, wine- 
whey, quinine, brandy, &c, may be indicated, and should be adminis- 
tered to fulfill the indications as they arise. The patient should be kept 
quiet, till the disease entirely passes off, and then great care should be 
taken to so regulate the habits of the patient, as to avoid any excitement 
of the body and mind, and that too for a long time. 

By thus fulfilling the indications as they arise, in each case without 
doing anything more, I am satisfied that many mild cases of tetanus, 
and some severe ones may recover, at least such has been the result of 
my observation in this disease. In localities where tetanus is liable to 
occur in new-born infants, prophylactic measures are all important, such 
as keeping the child clean, dry, and properly nourished, and allowing it 
good, drv, fresh air. 



HYDROPHOBIA. 321 

SECTION XIX.— HYDROPHOBIA— {Canine Babies.) 

By hydrophobia, from, idup " water" and $o/3o$ " dread," I mean that dis- 
ease involving the nervous system, the result of the entrance into the 
system of a specific virus from rabid animals, communicated generally 
by the bite of the animal so affected. It is probable that the hydro- 
phobic virus is contained exclusively in the saliva of the rabid animals, 
hence it is by the bite of the animal that the disease is almost invariably 
communicated to the human subject. This disease may, however, be 
communicated by bringing the poison saliva in contact with an excoriated 
surface, or with a mucous membrane. 

In the dog, wolf, cat, or some other animals, hydrophobia has at some 
period been originated spontaneously, and it is probable, I think, that the 
disease is now developed in these animals from general causes, indepen- 
dent of the direct contact of the virus. It is possible that the disease some- 
times occurs spontaneously in the human species, from want, hunger, and 
an undue degree of anger or mental excitement. When this disease has 
appeared to occur spontaneously in the animals most liable to it, it has 
followed the eating of unwholesome putrid food, and great rage, and the 
spontaneous symptoms in the human species, approaching most nearly to 
this disease, I believe have arisen from want, exposure and putrid food, 
or excessive hunger approximating starvation. 

The period which intervenes between the reception of the contagion 
of rabies, and the development of the disease, may vary from a few days 
to several weeks, months, and perhaps years, but it appears probable, 
that the most frequent period of incubation is from one to three months. 

Symptoms. — At an indefinite period after the reception of the virus, 
the wound is apt to assume a livid appearance, and it may discharge a 
thin, ichorous matter, before the accession of the hydrophobic symptoms. 
There is also more or less pain in the wound, which may pass along the 
nerves of the part towards their origin. During this period there is 
muscular prostration, flushes of heat, followed by chilliness, nausea, 
vomiting, thirst, constipation, and generally most of the symptoms which 
usually precede the development of febrile disease. 

These symptoms may continue for five or six days, when the patient 
feels a stricture about the throat, and finds a difficulty in attempting to 
swallow liquids ; which difficulty increases till it becomes impossible to 
swallow water, the distress being so great on attempting it that the very 
thought of water becomes intolerable to the patient. The disease being 
now fully established, the patient becomes nervous, irritable and excited; 
there is a copious secretion of saliva, stricture about the throat, embar- 
rassed and interrupted breathing, an apparent necessity for fresh air, 
and the whole frame is in a state of tremor, agitation and almost convul- 
sions. 

If the patient lies down to rest, he starts up again with apparent 
anguish of feeling: the countenance expressing anxiety, terror, or deep 
despair. An attempt to swallow liquids, or even the thought or sound 
of water poured from one vessel to another, and various other slight 
causes will throw the patient into painful agitation, with, perhaps, con- 
vulsive spasms of the most distressing character. Acute pains are felt 
21 



322 DISEASES OF THE NERVOUS SYSTEM. 

in the epigastrium, back of the neck, and at other points along the spine, 
and the patient is apt to spit from the mouth, almost convulsively, a 
viscid mucus which collects in the fauces. 

Remissions of partial quiet occur between the paroxysms, but during 
the exacerbations the countenance is wild and furious, the eyes are red 
and projecting, the muscles of the face, throat, chest, and perhaps ex- 
tremities are thrown into spasms; the arms are thrown about, and the 
fists clenched; there is foaming at the mouth, and sometimes a disposi- 
tion exhibited to bite whatever comes within reach of the patient. In 
violent cases, furious and maniacal raving occurs during the paroxysms, 
but during the intervals, in cases of less violence, consciousness is gene- 
rally retained and the patient appears quite rational, often appearing 
fearful that he may be allowed to inflict some injury upon his attendants 
during the insanity of his paroxysms. 

During the early stage of the disease, the tongue is furred, and there 
may be nausea and vomiting, but the pulse is sufficiently strong, and the 
skin warm or nearly natural; but as the disease advances, the pulse be- 
comes weak and feeble, the skin becomes cool and finally covered with 
an offensive viscid sweat; and at last the patient dies, either quietly, or 
in violent convulsions. Violent cases usually terminate fatally by the 
fifth day ; but it is possible that some cases may linger much longer than 
that, perhaps to the ninth or tenth day. 

Anatomical Characters. — In some cases, the post-mortem reveals 
nothing which might be supposed to throw any special light upon the 
disease, but, generally, I believe, the brain and spinal cord, or their 
meninges, are found to have been in a more or less congested state, and 
in some rare cases there may be found slight softening of the brain or 
spinal cord at some point. 

The mouth, tongue, fauces, oesophagus, and trachea, are found either 
reddened or else very pale, and the papillae of the tongue are often en- 
larged, especially on its back part. The mucous membrane of the 
stomach often exhibits signs of inflammation ; the lungs are found en- 
gorged ; the blood is found changed ; and the body tends rapidly to pu- 
trefaction after death. 

Diagnosis. — Tetanus and certain forms of hysteria are the only dis- 
eases with which hydrophobia is liable to be confounded, and the dis- 
crimination in most cases is attended with little or no difficulty. Hydro- 
phobia differs from tetanus in the dread of water, in its spasms being 
clonic instead of tonic, in the motion of the jaws being more free, and, 
finally, in there being a more copious secretion of saliva, and more de- 
rangement of the circulation, digestion, and mental faculties in hydro- 
phobia than in tetanus. 

Peculiar forms of hysteria, and other nervous affections, which may 
resemble hydrophobia, may generally be distinguished by the absence of 
an exposure to the poison of rabies, and by the dissimilarity in the 
essential symptoms of the two affections. In hysteria there is the 
alternate laughing and crying, "globus hystericus," &c. ; while in rabies 
there is the dread of water, copious secretion of saliva, &c, which do not 
attend hysteric or other nervous affections. 

Causes. — Hydrophobia had its origin, at some period, either in the 






HYDROPHOBIA. 323 

human species or in the lower animals, and when once originated, is 
readily communicated from one animal to another, and also from animals 
to the human species, and perhaps from man to man, if the saliva be 
brought to act upon an abraded surface, or a mucous membrane. 

The animals that have been known to communicate this disease from 
one to another, and to the human species, are the dog, cat, fox, wolf, 
jackal, and various other carniverous animals; and generally by the 
bite ; the saliva, which contains the poison, being thus brought in con- 
tact with abraded or lacerated parts. It is very probable, however, that 
the saliva of all the lower animals laboring under this disease, and even 
of man, if brought to act upon an abraded surface, or a mucous mem- 
brane, may communicate the disease. But as the herbiverous animals 
and the human species are less given to biting than the carniverous ani- 
mals, the disease is very rarely communicated by them, by biting at 
least. 

While it is true that this disease is now generally communicated by 
the virus in the saliva of rabid animals, by a bite or otherwise, I believe 
that genuine hydrophobia may arise spontaneously in the lower animals, 
or even in the human species ; though it is probable that such an event 
may very rarely occur. That it may now so occur in the one or the 
other appears to me the more probable, when we remember that it has 
so arisen at some period ; and I can see no reason why the same liability 
may not now exist, and the same accidental causes be brought to bear, 
in developing the disease. Among the accidental influences which it 
appears to me may have an agency in producing hydrophobia independ- 
ently of the direct contact of the saliva of a rabid animal, are extreme 
madness, want and exposure, with hunger approaching starvation, or 
else the use of filthy, unwholesome, and putrid articles of food, such as 
the human species occasionally, and dogs and other carniverous animals 
very often partake of. 

It is sometimes a matter of importance to decide on the existence of 
hydrophobia in the lower animals, and especially in the dog, that proper 
precautions may be taken, if necessary. This may generally be done 
by noticing carefully the appearance and motions of the animal. 

The animal has at first an altered suspicious look ; is restless, and ex- 
hibits a disposition to take up, and even swallow bits of straw, hair, wood, 
&c, and not unfrequently vomits. As the disease advances, he is apt to 
become exceedingly irritable, quarreling with other dogs, and flying 
furiously at strangers, resisting correction ; being rather enraged instead 
of terrified, by threatened chastisement. A copious secretion of saliva 
flows from the mouth ; there is extreme thirst ; labored breathing ; a sort 
of howling bark ; he is constantly in motion ; has visual illusions ; and 
finally the animal becomes paralytic, totters and falls ; and dies by the 
fifth or sixth day, either quietly, or in more or less violent convulsions. 

The period of incubation in the dog, varies from three or four days, to 
as many weeks, being shorter than in the human species. 

Nature. — It appears to me probable, that hydrophobia is the direct re- 
sult of a specific animal poison, derived either from the saliva, of a rabid 
animal, or from various unwholesome putrid articles of food ; the disease 
being called into activity from a latent state, perhaps by various acciden- 



324 DISEASES OE THE NERVOUS SYSTEM. 

tal causes, among which fear, privation, and extreme anger or rage, are 
probably the most frequent. 

Now that a specific poison should thus be taken into the system, from 
the saliva of a rabid animal, or be generated in the system from want, 
privation, and putrid articles of food ; and there remain for a time in a 
latent state ; and finally, by some exciting cause, such as violent passions, 
or irritation of any kind, produce sufficient derangement in the nervous 
system, including the brain and spinal cord, to develop all the symptoms 
of hydrophobia, is not so very strange. If then, there is a specific 
morbid poison in the system in this disease, I can see no reason why it 
should not produce exactly the effects it does upon the cerebro-spinal, 
and nervous system ; and that there should be an effort on the part of the 
system to eliminate the morbid poison, which has produced the disease, 
by the salivary glands, is to me no more strange than that the poison 
producing mumps should fall mainly upon the parotid glands, and pro- 
duce a specific inflammation. 

Now the fact that the blood is often found in an altered condition in 
hydrophobia, and that the bodies of patients dead of this disease very 
soon become offensive, and tend rapidly to putrefaction, favor the idea 
of a poison in the blood, which is producing the disease ; and that an 
effort on the part of the system to eliminate the poison through the 
salivary glands, may render the saliva poisonous ; and hence the propa- 
gation of the disease by biting, or contact of the saliva. 

Prognosis. — I believe that the prognosis in genuine hydrophobia, may 
be set down as invariably unfavorable. It is possible, however, that very 
many cases of nervous derangement, produced by fear, from the bite of 
a rabid animal, may recover after many svmptoms analogous to hydropho- 
bia have been developed, when none of the virus has really entered the 
system. And it is possible that the disease itself, may be palliated, and 
the patient partially recover, and live on for several years ; as happened 
in one case, bitten by a rabid cat, that has fallen under my observation. 

Treatment. — Immediately on receiving a bite by a rabid animal, or on 
receiving a portion of the saliva upon a raw surface ; the part should be 
washed clean, and then removed by a free use of the knife ; carefully 
avoiding to leave any of the affected part. A cup may then be applied 
over the wound, in order to draw out a little blood, and with it any poi- 
son that may have reached it. After removing the cup, a stick of lunar 
caustic may be thoroughly applied to the cut surface ; and then, if 
necessary a bread and milk poultice applied till the surface is thrown 
off, after which simple cerate may be all the dressings necessary, during 
the healing of the wound. 

If, however, the wound from the bite be of a deep lacerated character, 
and in a situation in which it cannot be readily removed ; if it be in a 
finger or toe, the limb should be amputated, as a less calamity than risk- 
ing the effects of the poison and the chances of hydrophobia. But if 
the bite be in a situation in which it does not appear judicious to ampu- 
tate, the wound should be carefully washed with warm water, as much 
of its surface removed as may be with the knife, caustic thoroughly ap- 
plied, and the wound kept open by blisters, poultices, &c, to favor as 
far as may be the elimination of the poison. If, however, in such cases, 



NEURALGIA. 325 

at any future period, hydrophobic symptoms make their appearance, the 
limb should be amputated at once, as affording, perhaps, the only chance 
of saving the life of the patient. 

At any period within two years after the reception of the poison, the 
treatment I have here suggested may be resorted to, in case it was 
neglected at first. If the patient is of a good constitution, nothing 
further need be done, except that he should be made to conform rigidly 
to the laws of health in every respect. But if the patient be feeble, or 
debilitated, two ounces of the cinchona bark may be put into a quart of 
good port wine, and the patient directed to take a wine-glassful after 
each meal, for a time, to sustain the strength and prevent, if possible, 
the ordinary effects of this morbid agent upon the system. In these 
debilitated cases in which the wine is contraindicated, or does not agree, 
one or two grains of the sulphate of quinine may be given instead, and 
continued for a time, care being taken to keep the mind at ease, and the 
various functions of the body as well performed as possible. If, how- 
ever, after every reasonable precaution has been taken, the disease 
makes its appearance, the patient should be kept from injuring himself, 
or any one else, and treated, if at all, upon general principles ; fulfilling, 
as far as may be, the indications as they arise. The feet of the patient 
may be placed in warm water, a mild cathartic administered, and cups, 
wet or dry, applied to the back of the neck, or along the spine ; the 
patient quieted, as much as possible, by moderate doses of the fluid ex- 
tract of hops or valerian; and, finally, if the strength fails, quinine, 
broths, wine-whey, &c, may be given, as long as the patient is able to 
swallow them, that our duty in the case may be fully done. 

SECTION XX.— NEURALGIA. 

By neuralgia, from v£upoi/ 3 a u nerve," and o&yoj "pain," I mean that de- 
rangement of the nervous system in which there is at some point in its struc- 
ture, acute nervous pain, without inflammation or any apparent structural 
change at the seat of the pain. Neuralgia may occur in any part of the 
system, as well in parts supplied by the ganglionic system of nerves, as 
in those supplied by the cerebro-spinal, as there are numerous branches 
connecting the two systems throughout their whole extent. 

Symptoms. — The pain in neuralgia is always of a sharp, acute, dart- 
ing character, passing rapidly from the seat of the irritation along the 
course of the affected nerve. The pain may come on and be continuous, 
or it may remit at irregular periods, or it may even intermit, the pa- 
roxysms coming on at regular periods, in such cases being generally 
quotidian or tertian. 

During the paroxysms of neuralgia the pain is severe, with frequent 
transitory shocks of darting pain, so extremely agonizing as sometimes 
to cause a temporary loss of reason and consciousness. At such times 
the irritated parts are sometimes tender to the touch, a very slight touch 
often producing more suffering than firm pressure. During the conti- 
nuance of neuralgia, there may be more or less congestion at the seat of 
the pain, and slight tenderness may remain even after the neuralgia has 
passed off. In violent cases of neuralgia, the muscles of the affected 



326 DISEASES OF THE NERVOUS SYSTEM. 

parts are liable to become affected with spasms, and when it occurs in 
the face, there may be a copious secretion of saliva, and flow of tears 
during the paroxysms. 

Strictly periodical neuralgia I believe is generally of malarious origin, 
partaking very much of the nature of intermittent fever, except that 
there is no febrile reaction as in ague. But cases of neuralgia not of 
malarious origin, may only slightly remit, and some cases of a chronic 
character, continue almost uninterruptedly, for weeks, months, or even 
years, producing the most severe and protracted suffering. There is 
not an organ or tissue of the body in which neuralgia may not be deve- 
loped, but some parts are more liable to become the seat of it than others, 
and among the most frequent are the following : 

The head is very liable to a neuralgic affection, and in some cases 
being confined merely to the scalp, while in others, the brain is its spe- 
cial, if not, exclusive seat. Its symptoms differ from those of inflamma- 
tion, in being confined to a particular part, and also in the absence of 
general febrile excitement. This variety of neuralgia generally affects 
the whole of one side of the head, but it is sometimes confined to the 
temples of one or both sides. 

The face is exceedingly liable to become affected with neuralgia, and 
when it is, one side only of the face may suffer, all the parts supplied 
by the portio dura generally being more or less involved. In a case of 
this character that fell under my care a few years since, which was 
evidently the effects of the continued use of tobacco, the paroxysms 
which came on at evening, were attended with so much pain, that the 
patient became uncontrollable, groaning, screaming, and raving alter- 
nately, and getting little or no sleep for several nights. 

The optic nerves is sometimes the seat of severe and protracted neu- 
ralgia. It may affect both nerves, but it is often confined to one side, 
and is attended with deep, sharp and acute pain, which produces more 
or less intolerance of light. 

Neuralgia sometimes affects one or both of the arms, and it may be 
confined to one or all the brachial nerves, depending in the one case 
upon irritation of the spine at the origin of the brachial nerves, while 
in the other case, it depends upon some accidental disturbance in the 
nerve at some point between the seat of the pain and the brachial 
plexus. 

The intercostal nerves are exceedingly liable to become the seat of 
neuralgia, and generally of a severe and darting character, sometimes 
very much resembling the pleuriatic pain. This variety of neuralgia 
depends upon congestion or irritation at or near the origin of the inter- 
costal nerves. 

The breasts of females sometimes become the seat of neuralgia, either 
one or both at the same time. In cases of this kind I have generally 
found a tenderness of the spine at the point which supplies them with 
nerves, and the neuralgic pain more or less increased by pressure on 
each or one side of the spine. 

The abdominal muscles are occasionally, though not very frequently, 
the seat of neuralgia ; the dorsal portion of the spine in such cases 
being more or less congested, irritated or deranged as a cause. I have 



NEURALGIA. 327 

noticed this variety of neuralgia most frequently during irregular mias- 
matic fevers, in some cases of which it has been very severe. 

One or both the hive?' extremities are sometimes the seat of severe 
and obstinate neuralgia. It generally follows along the ischiatic nerve, 
or it may affect mainly the crural or tibial nerves. This affection gene- 
rally depends upon congestion or irritation in the lower portion of the 
spinal cord, in the lumbar or sacral nerves, or else in some disturbance 
of the nerve between the seat of the pain and the origin of the nerve. 

Besides these external seats of neuralgia occurring in parts supplied 
almost exclusively with nerves from the brain and spinal cord, neuralgia 
is liable to occur in all the internal organs of the body, from the larynx 
to the rectum ; affecting more or less those vital parts which, though 
mainly under the influence of the ganglionic system, are nevertheless 
more or less supplied by the cerebro-spinal nerves. Of the internal 
parts, liable to become the seat of neuralgia, the larynx, lungs, heart, 
stomach, liver, kidneys, womb, testicles, bladder and rectum, are, accord- 
ing to my observation, by far the most frequent seats. 

When neuralgia effects the larynx or lungs, the pain is not from the 
nature of the structures involved, very acute, but there is very great 
distress, and an intolerable and almost constant disposition to cough. 

When neuralgia affects the heart it is attended with the most excruci- 
ating pain and very great distress, affecting more or less the various 
functions of the body, and especially the circulation.* 

When the stomach becomes the seat of neuralgia, there is generally 
a most unpleasant pain experienced, coming on often in paroxysms, and 
in very chronic cases, an hour or so after each meal. 

The liver is quite often the seat of neuralgia, being attended with 
severe sharp, darting pains in the right hypochondrium, and more or 
less pain in the right or left shoulder. Neuralgia of the liver may be 
distinguished from an inflamed condition, by the want of febrile excite- 
ment in the neuralgic affection, and also by the slight functional derange- 
ment which occurs in such cases. 

The kidneys are exceedingly liable to neuralgia, affecting sometimes 
one and at others both kindeys, and appearing in many respects very 
much like nephrites. It may be distinguished, however, from inflamma- 
tion by the intermittent character of the pain, want of tenderness, and also 
of a general febrile excitement in the nephralgic or neuralgic affection. 

The uterus is occasionally the seat of neuralgia; the pain being of a 
darting, lancinating character, and the affections being attended in some 
cases with slight hysteric symptoms, and more or less sympathetic irrita- 
tion of the whole system. 

The testicles are liable to neuralgia, the affection being often attended 
with a dull heavy pain in the spine, at or near the origin of the sper- 
matic nerves. In one case of this character, that came under may care 
a few years since, the result of masturbation and excessive venery, the 
disease had been of several years standing, and was of a most distressing 
character. 

Neuralgia may affect the bladder, and when it does, it is apt to pro- 
duce considerable local and general disturbance ; but it may be distin- 

* See neuralgia of the heart or augina pectoris, in another part of this work. 



328 DISEASES OF THE NERVOUS SYSTEM. 

4 

guished from cystitis, by the absence of a general febrile excitement, in 
this affection. 

The rectum is liable to a neuralgic affection of a most distressing cha- 
racter, in some cases being remittent or intermittent; but often of a 
chronic and continued character. Cases of purely intermittent neural- 
gia of the rectum are generally, I believe, of malarious origin. 

It is probable that in neuralgia of all the internal vital organs of the 
body, there is in addition to an irritation of their spinal nerves, either 
at the spine, or at some point between the seat of the pain and their 
origin, also derangement with irritation, either primary or secondary, 
of the ganglionic or sympathetic nerves, by which these vital organs 
are also more especially supplied. 

The spine is liable to a species of neuralgic irritation, which may 
locate at any point ; but which more frequently passes from one point 
to another, along the spine, varying its seat, as I believe, according to 
the general strength of the patient. If the strength is declining, I have 
noticed that the point of local irritation is apt to pass towards the brain. 
But if the general strength is improving, the local point of neuralgic 
irritation will generally pass from the brain towards the lower portion 
of the spine, and finally disappear altogether. 

As this local neuralgic irritation passes along the spine, opposite the 
different organs, their functions are apt to be more or less affected. If the 
brain be the seat of this neuralgic irritation, there is generally an undue 
degree of mental excitement ; if it be in the cervical portion of the spine, 
there is more or less derangement in the functions of the larynx, heart, 
and lungs ; if it be in the dorsal region, the stomach, liver, or intestines 
have their functions more or less affected ; and finally, if the irritation 
occupies that portion of the spine opposite the kidneys, these glands 
become deranged in their functions, generally secreting an undue quan- 
tity of clear transparent urine. The same is also true in relation to the 
uterus; testicles, bladder, and rectum ; and in fact of all the internal 
organs, as well as external parts of the body. 

This neuralgic irritation of the spine sometimes occupies the same 
location for a long time, while in other cases it will pass rapidly from 
one extreme of the spinal cord to the other, in the course of a few 
hours ; seldom occupying two distinct points of the spine at the same 
time, at least in any great degree. 

Anatomical Characters. — Dissections have afforded no very positive 
evidence as to the nature of this disease. Generally, however, signs of 
congestion, irritation, or inflammation, have been detected in the cra- 
nium, spinal canal, or in the nervous trunk, at some point between the 
seat of the neuralgia, and the origin of the nerve. 

Diagnosis. — Neuralgia may be distinguished from inflammation by 
the sharp and darting character of the pain ; by its intermitting tend- 
ency ; by the absence of any special tenderness to firm pressure ; and 
also by the absence of any general febrile excitement. And besides, in 
neuralgia, the pain follows the track of some prominent nerve or nerves, 
which is not so remarkably the case in inflammation. 

Causes. — I believe that hoino-miasmata and atmospheric vicissitudes 
are among the most frequent causes of neuralgia. It is probable that 



NEURALGIA. 329 

the paludal poison operates through the blood, upon the brain and ner- 
vous system, to produce neuralgia, in the same manner that it does to 
produce intermittent fever, though generally in a less degree ; while 
atmospheric vicissitudes act by interrupting the cutaneous exhalation, as 
in producing catarrhal fevers, though perhaps in a less degree. 

It is probable also that the electrical state of the atmosphere has an 
important agency in producing neuralgia, a damp or low electrical state 
of the air developing the disease in debilitated, anaemic patients, while 
an opposite state may be an exciting cause in plethoric, or sthenic con- 
stitutions. Gastro-enteritis is also a frequent cause of neuralgia, and 
sometimes of intermittent neuralgia, especially if the system has at the 
same time been exposed to a malarious influence, many marked cases of 
which have fallen under my care during the past few years. Local in- 
juries are also frequent causes of neuralgia, especially if important 
nerves are involved in the wound or injured part. Indigestible articles 
of food, taking food at irregular hours, masturbation, excessive venery, 
onanism, and the use of tobacco and intoxicating liquors, are very fre- 
quent causes of neuralgia. 

A weak or depraved state of the blood, in consequence of which the 
circulation is illy performed, and therefore local congestion produced, is 
probably the condition of the system most compatible with neuralgic 
irritation. In this condition a very slight exciting cause will develop 
the affection. This condition, I believe, is the immediate cause of that 
neuralgic irritation which affects the brain and spinal cord, when no 
other exciting cause happens to be operating. 

Now, while the above are some of the most prominent causes of neu- 
ralgia, I believe that the immediate cause is pressure, congestion, irrita- 
tion, or inflammation, either of the brain or spinal cord, or their menin- 
ges, or else* at some point along the nerve, between the seat of the pain 
and the origin of the nerve. 

Nature. — As either pressure, congestion, irritation, or inflammation, 
at some point in the brain, spinal cord, or nerves, or else in their invest- 
ing membranes, very generally exists as the direct cause of the neural- 
gia, it appears to me probable that the pain is from a derangement in 
the distribution or flow of the nervous influence, produced by its inter- 
ruption, either at some point along the nerve, or in the spinal cord or 
brain. Further than this, I am not disposed to offer any opinion as to 
the nature of this affection. 

Treatment. — The indications in the treatment of neuralgia are to cor- 
rect the derangement of the system, to subdue any local congestion or 
irritation that may exist in the brain or spinal cord, or at any point in 
the nerve involved, to equalize the circulation, and to restore the 
strength and tone of the blood and nervous system. The direct and re- 
mote cause should also be sought out, and if possible removed or cor- 
rected, as well as all the habits of the patient, that might serve to de- 
prave or weaken the blood, or in any way injure the tone of the nervous 
system. The state of the digestive organs should be inquired into, and 
if there is indigestion, or constipation of the bowels, the condition should 
be corrected, by antacids, laxatives, vegetable tonics, &c, and a pro- 
perly regulated diet directed. 



330 DISEASES OF THE NERVOUS SYSTEM. 

If a malarious influence has been operating to produce an intermittent 
neuralgia, two or three blue pills or two grains of podophyllin may be 
given, and followed by half an ounce of castor oil or of the sulphate of 
magnesia, and if there is much gastric irritation, a blister should be 
applied to the epigastrium; after which, the patient should be treated 
in all respects as for intermittent fever ; twelve grains of the sulphate of 
quinine may be given in divided doses during the six hours next preced- 
ing the expected paroxysm. Two-grain doses may be given every hour 
till four doses have been taken, but four grains may be given at the fifth 
dose, which should be administered at one hour anterior to the expected 
paroxysm. As soon as the paroxysms are arrested, the medicine may 
be continued, dropping the first dose each day till but one dose is given, 
and then the quinine should be continued in one or two grain doses after 
each meal, for a time, to prevent a return of the disease. 

If, however, the neuralgia be continued, or only slightly remittent, 
and continues after removing the cause, correcting the digestion, &c, 
some permanent local cause should be suspected along the nerve, in the 
spine, or perhaps in the brain itself. If, on examination, a local irrita- 
tion be found at either of these points, cups should be applied and re- 
peated if necessary ; and later, should the disease continue, blisters may 
be of service, and perhaps pustulation with tartaric emetic ointment. 

If, on examination, no local irritation be found operating as cause of 
the pain, and requiring cups, blisters, &c, and the patient be anaemic, 
congestion from debility, in some portion of the brain or spinal cord, 
with the irritation of the nervous system, which an anaemic state pro- 
duces, are evidently the conditions which require to be corrected. In 
such anaemic cases of continued neuralgia, twenty or thirty grains of the 
subcarbonate of iron may be given at first, four times per day, till the 
neuralgia subsides, and them; it may be continued in three or four grain 
doses, after each meal, till the integrity of the blood is fully restored. 
Or the iron by hydrogen, or the ferrocyanuret may be given instead of 
the subcarbonate, in case that should in any way disagree. As soon 
as the blood is thus corrected, and the tone of the nervous system resto- 
red, the circulation will be equalized, the cerebro-spinal congestion and 
nervous irritation overcome, and thus the neuralgia be permanently 
subdued. 

Anodynes, either externally or internally, may become necessary to 
secure rest, but further than that I do not believe they are generally 
indicated, as they are liable to derange the various functions of the body, 
and permanently increase, rather than correct, nervous irritability. 
During the violence of the neuralgia, fifteen drops of the fluid extract of 
hyoscyamus, or ten drops of the fluid extract of the cannabis indica may 
be given at evening, to secure rest; and in very severe cases, in which 
the pain becomes a greater calamity than the remedy, similar doses of 
one of these anodynes may be given every six hours, till the violence of 
the pain subsides, when it should be gradually discontinued. 

Externally, the tincture of opium may sometimes be of very essential 
service, especially in neuralgia of the spine ; in such cases, thirty or 
forty drops of the laudanum may be rubbed along the painful portion at 
evening, with very happy effect. It may also be applied in neuralgia of 



AMAUROSIS. 331 

other parts, should an external anodyne become necessary. By thus 
removing the cause and correcting the general and local derangements 
of the system upon which the neuralgia depends ; not only the neuralgia 
is overcome, but the integrity of the system is restored. 

SECTION XXI.— AMAUROSIS. 

By amaurosis, from a^avpoj, "obscure," I mean an affection of the 
optic nerve, or its. expansion, the retina, in which it becomes incompe- 
tent to receive or convey to the brain clear visual impressions of objects. 

This impaired condition, or loss of sensorial function of the optic 
nerve and its expansion, may depend upon organic disease, or merely on 
functional torpor, or paralysis of these parts, without any structural 
lesion. 

Among the organic conditions which give rise to this affection, are 
extravasation of blood, structural lesion, and deposition of lymph upon 
the surface of the retina ; morbid growths, dropsy, and atrophy within 
the eye, and also sanguineous or serous effusion, tumors, &c, pressing 
upon the optic nerve within the head. The loss of functional power of 
the retina and optic nerve may depend either upon vascular turgescence 
of the retina, or sheath of the optic nerve, or on deficient arterial cir- 
culation in these parts, or it may be the result of an idiopathic paralysis 
or loss of the sensorial power of the retina and its nerve. 

Symptoms. — Functional amaurosis usually comes on gradually, the 
patient at first complaining of some weakness of sight, which goes on 
gradually increasing till almost or quite total blindness is the result. 
There is usually more or less pain in the head and temples, which dimi- 
nishes as the dimness of vision increases, and frequently ceasing alto- 
gether, when the amaurosis is complete. In cases, however, in which 
the pain continues and increases, we may suspect the existence of some 
organic affection as the cause. The eye in amaurosis has generally 
nearly its natural appearance, only the pupil is usually dilated, and im- 
movable, and sometimes irregular in shape. 

Diagnosis. — Amaurosis may generally be distinguished from incipient 
cataract by a careful attention to all the symptoms. The dilated or 
possibly contracted, and generally fixed or immovable condition of the 
pupil may serve in most cases to characterize amaurosis. In imperfect 
amaurosis, vision is frequently increased or diminished under different 
states of the circulation, while in incipient cataract no such change 
occurs. 

In amaurosis the sight or pupil of the eye retains its natural dark ap- 
pearance, while in cataract it very soon acquires a lightish milky ap- 
pearance. And besides, in cataract, the patient is apt to see more dis- 
tinctly just after sunset, on account of a dilatation of the pupil which 
takes place as the light is withdrawn, while such is not the case in 
amaurosis. 

Causes. — When amaurosis is not the result of organic structural dis- 
ease of the optic apparatus, it arises, in most instances, from pressure 
on some portion of the visual nervous texture. Even in those cases that 
arise from excessive losses of blood, it is probable that a passive con- 
gestion of the retina or optic nerve is the immediate cause of the disease. 
Amaurosis may also sometimes depend upon mere functional torpor, 



^32 DISEASES OF THE NERVOUS SYSTEM. 

from previous over-excitement of the retina and optic nerve, with dimi- 
nished vitality or sensibility of the nerves. 

Among the exciting causes of amaurosis are metastasis of other affec- 
tions, suppression of the catamenial or hemorrhoidal discharges, the 
healing up of old ulcers, and the long continued use of tobacco and in- 
toxicating liquors. 

Prognosis. — The prognosis in all cases depending upon organic lesion, 
may be regarded as unfavorable ; but when the amaurosis is incomplete, 
and not attended with protracted pain in the head or eyes, and the 
pupil retains its natural shining appearance, a cure may reasonably be 
expected. 

Treatment. — The imprudence or cause which has been operating to 
produce the disease should be sought out, and removed if possible, and 
the general and local derangement corrected as far as may be, by a 
judicious course of treatment. At first, a cathartic of calomel and 
castor oil may be administered, and also a little blood taken from the 
temples and back of the neck, by cups ; after which a pill of aloes and 
rhubarb may be given each day, after dinner, to correct the digestion, 
and regulate the bowels. As an alterative, a pill composed of two 
grains of the extract of conium, and two grains of blue mass, may be 
given, morning and evening, and continued for one or two weeks, de- 
pending upon the severity of the case ; dry cups being applied to the 
temples and back of the neck each day, or every two days. After 
having continued the blue mass and conium as long as is expedient, it 
should be discontinued, and the iodide of potassium given in five grain 
doses three times per day, and continued for a long time. Blisters 
should now be applied to the temples, back of the ears, and back of the 
neck, and repeated; the patient being allowed a proper diet, and if 
necessary, iron to restore the blood, and finally strychnine, in small 
doses, if a nervous tonic should be required. 

SECTION XXII.— SINGULTUS— {Hiccough.) 

By singultus or hiccough, I mean that disturbance of the phrenic 
nerve, attended with sudden involuntary contractions of the diaphragm, 
with simultaneous contraction of the glottis, producing a peculiar laryn- 
geal sound. 

The phrenic nerve it will be remembered is formed from the third, 
fourth, and fifth cervical nerves, with a branch from the sympathetic. 
It descends to the root of the neck, enters the chest, passes through the 
middle mediastinum in front of the root of the lung to the diaphragm, to 
which it is distributed, some of its filaments reaching the abdomen through 
the openings for the oesophagus and vena cava, and communicating 
with the phrenic, solar, and hepatic plexus. 

Symptoms. — The phenomena of hiccough consists in a sudden and 
rapid inspiration, suddenly followed by expiration, the movements 
being accompanied by a noise, not attending common respiration. 
These convulsive movements succeed each other at intervals of a few 
seconds, and are attended with more or less uneasiness at the prascordia, 
sometimes amounting to actual pain. 

A paroxysm of hiccough may last from a few minutes to hours, days, 
weeks, or even months, but I have seldom known a case to continue 



SINGULTUS. 338 

more than two or three days, and often no more than a few hours, or 
even minutes. Generally in cases that are protracted, it is not entirely 
continuous, slight remissions or even intermissions occurring every few 
hours. At least such has been the result of my observation, in cases of 
hiccough. 

Hiccough being purely a nervous affection, is more annoying than 
dangerous. It may, however, be indicative, in some cases, of a condition 
of the system, fraught with more or less danger. It is liable, like many 
other nervous affections, to assume an intermittent form, the paroxysms 
occurring at regular hours each, or every other day, &c; the disturbance 
of the phrenic nerve, in such cases, being probably the result of some 
general derangement of the nervous system of a periodical character. 

Causes. — In order to appreciate the causes which operate in producing 
hiccough, it is necessary to remember that the direct cause of the spasm 
of the diaphragm is probably a disturbance of the phrenic nerve, which 
we have seen receives a branch from the sympathetic ; and also communi- 
cates freely with the phrenic, solar, and hepatic plexus of nerves ; thus 
bringing the diaphragm into close sympathetic relation with the stomach, 
and all the abdominal and pelvic viscera. 

Now, any cause capable of producing, either directly, or by sympathy, 
a certain degree of disturbance, or derangement of the phrenic nerve, 
will produce spasmodic contraction of the diaphragm, which, with the 
contraction of the glottis, develop the phenomena of hiccough. We find 
then, as we should suppose, that the most frequent exciting causes are 
the swallowing of improperly masticated food, in a dry state ; over dis- 
tension of the stomach ; flatulence ; acidity of the stomach ; the use of 
alcoholic drinks; congestion, irritation, or inflammation of the spinal 
marrow ; and finally mental emotions, and general nervous derangement 
from any cause. 

Treatment. — The indications are evidently to first quiet the undue 
excitability of the phrenic nerve, and then to correct the local, or gene- 
ral conditions of the system, upon which the phrenic disturbance depends. 

If the hiccough be from swallowing improperly masticated food in a 
dry state, a draught of cold water, or a little sugar or simple syrup, will 
generally allay the irritation and hiccough at once. If it depend upon 
spinal irritation, a dry cup on each side of the spine, in the cervical 
portion, or opposite the diaphragm, or to the epigastrium, may stop the 
spasms at once. A full inspiration, and then holding the breath for a 
short time, may arrest the spasm in slight cases. And finally, a sudden 
surprise, frightful or agreeable, will very often arrest hiccough. 

In the worst case I ever saw, in which all the usual remedies had been 
judiciously applied in vain, by his medical attendant, I succeeded in ar- 
resting it, by taking the light from the sick room, and giving as my 
reason, to the patient and his attendants, that if left in the dark, he 
could not see to hiccough. The patient had been very sick, and his 
nervous system was in a high state of excitability ; and yet, ridiculous 
as was the idea of being unable to see to hiccough, the impression it made 
upon the nervous system, through the mind, so far affected the phrenic 
nerve, as to suspend the spasms of the diaphragm, and the patient 
speedily recovered. 



384 DISEASES OF THE DIGESTIVE SYSTEM. 

In obstinate cases, in which though the paroxysms may be arrested, 
they are liable to return, from very slight causes ; attention should be 
directed to the local or general conditions of the system, of which the 
hiccough is symptomatic. If there be acidity of the stomach, indiges- 
tion, or constipation ; a tcaspoonful of magnesia may be given each 
morning ; and if necessary, a pill of aloes and rhubarb at evening, till 
the gastro-intestinal derangement is corrected ; after which, if the patient 
is ansemic, iron with mild vegetable tonics, &c.,may be necessary, till the 
tone of the system is restored. 



CHAPTER VIII. ' 
DISEASES OF THE DIGESTIVE SYSTEM. 



SECTION I.— STOMATITIS— {Sore Mouth.) 

By the digestive system, I mean the alimentary canal and its accessory 
organs and parts concerned in digestion. The digestive tube, it will be 
remembered, is lined throughout its whole extent with a mucous mem- 
brane, which is a continuation of the skin. Exterior to the mucous 
membrane is a muscular coat, while that portion of the canal forming 
the stomach, small and large intestines, has an external serous coat, 
which extends itself and lines the cavity of the abdomen. Its accessory 
organs, the salivary glands, the liver and pancreas, are glandular struc- 
tures having ducts emptying into the canal, while the spleen, though 
without a duct, is probably concerned in the digestive process. 

Having thus called to mind the anatomy of the digestive system, let 
us before we proceed to the consideration of stomatitis, remember that 
digestion commences with the mastication and mixing of the salivary 
secretion in the mouth ; that the food is still further dissolved by the 
gastric secretion in the stomach ; that the bile and pancreatic secretion 
changes it still further ; and finally that the nutritious portion is taken 
up by the absorbents along the intestines, carried by the lacteals 
through the mesenteric glands which produce another change, and then 
goes to the thoracic duct through which it passes into the blood. 

Having thus taken a glance at the anatomy and physiology of the 
digestive system, the diseases of which will occupy the present chapter, 
let us now proceed to the consideration of inflammation of the mucous 
membrane of the mouth or stomatitis, the subject of our present section. 
By stomatitis, from Sto/xa, "the mouth," and itis inflammation, I mean 
here inflammation of the mucous membrane of the mouth, in whatever 
form it may occur. 

Symptoms. — Simple or common inflammation of the mucous mem- 
brane of the mouth is characterized by redness, heat and tenderness, if 



STOMATITIS. 335 

the tissues beneath become involved. Blisters may form, and even 
ulcerations occur, involving more or less of the mucous membrane, 
especially in certain depraved conditions of the system. There is gene- 
rally a copious secretion of saliva, the sense of taste is impaired, masti- 
cation is difficult, the tongue is covered with a white fur, or else red and 
glossy, the gums may swell, and perhaps ulcerate, and in severe cases a 
slight symptomatic fever may be developed. 

Thrush is another form of inflammation of the mouth occurring at all 
ages, but more frequently in early infancy ; and presents, in addition to 
the ordinary symptoms of mucous inflammation, patches of curd-like 
matter, appearing first on the inside of the under lip, and extending 
gradually to the inside of the cheeks, roof of the mouth, tongue, and 
perhaps fauces. This curd-like exudation may become thick, assume a 
darkish color and fall off, its place being supplied by a new crop ; and 
this may occur repeatedly, the mouth becoming hot, and the voice more 
or less changed in most cases. In some cases the disease extends to the 
stomach and intestines, the patient being afflicted with acidity, colic 
pains, diarrhoea, vomiting, &c, and frequently with more or less febrile 
disturbance. 

Follicular inflammation is another form of stomatitis, characterized by 
red eminences, especially upon the tongue and palate ; which inflamed 
eminences are apt to pass on to ulceration, being distinct or confluent, 
according to the number of granules involved. 

Aphtha is still another form of stomatitis, and consists of small ulcers, 
the result generally of a vesicular eruption. When the ulcers are fully 
formed they are whitish, painful, and surrounded by more or less redness 
and inflammation, and if they are confluent, more or less constitutional 
disturbance attends. 

Ulcerative Stomatitis consists of ulcers, which may occur in any part 
of the mouth, having a white or darkish surface, and being surrounded 
by more or less inflammation and swelling. The mouth becomes swelled, 
the ulcers are painful, the breath becomes offensive, there is a copious 
secretion of saliva, and the disease is attended with more or less febrile 
excitement. 

Nursing Sore Mouth is an ulcerative inflammation of the mouth, oc- 
curring in the latter months of pregnancy, or in women while suckling. 
It is attended with a loss of taste, heat in the mouth, tenderness, a 
smooth, red tongue, a copious secretion of saliva, diarrhoea and emacia- 
tion, and unless arrested it may terminate fatally. 

Gangrenous Inflammation of the mouth is most frequently met with 
in children, but it may occur at any age if the system be in a certain 
morbid or depraved state. There is, in some cases, a slight inflamma- 
tion, and soon a grayish eschar, either on the gums or at some point in 
the mouth, attended with some swelling, if it be upon the inside of the 
cheek. The patient becomes languid and weak ; the slough spreads ; 
the breath becomes fetid ; the alveolar processes become necrosed ; the 
teeth fall out, and thus the disease passes on, till portions of the cheek, 
palate, and upper jaw are destroyed, and the patient finally dies from 
extreme exhaustion. 

Mercurial Stomatitis commences with a slight redness and swelling of 



336 DISEASES OF THE DIGESTIVE SYSTEM. 

the gums, a metallic taste, and increase of the salivary secretion ; the 
gums become tender; there is stiffness of the jaws; the palate becomes 
swelled ; the breath is offensive ; ulceration occurs ; the mouth is opened 
with difficulty ; hemorrhage may occur ; and in bad cases, sloughing may 
take place, and the bones of the jaw be laid bare. 

Such, then, are the symptoms peculiar to the simple and other varie- 
ties of stomatitis, the causes of which we will now proceed to consider. 

Causes. — The different varieties of stomatitis, as we have seen, may 
arise from various causes : the simple from direct irritants ; thrush from 
impure air, unwholesome diet, &c. ; the follicular from the exanthema- 
tous fevers, phthisis, or inflammation of the abdominal viscera ; aphtha 
from gastro-intestinal irritation or disturbance ; the ulcerative from want 
of cleanliness, bad air, deficient or improper food ; the nursing from the 
puerperal state ; the gangrenous from a malarious influence, insufficient 
or unwholesome food, crowded apartments, &c. ; and the mercurial from 
the improper use of that mineral, especially in scrofulous, debilitated and 
depraved constitutions. 

Now, while these various causes operate to produce different forms of 
stomatitis, it is probable that if we except direct irritants, and perhaps 
the use of mercurials, the other causes may operate in producing any 
form, to which there is in the system, either a hereditary or acquired 
predisposition. Now, the predisposition to stomatitis, consists, as I 
believe, in a debilitated, depraved, and deranged condition of the system, 
and especially of the digestive apparatus and its functions; in conse- 
quence of which, the mucous membrane of the mouth takes on some one 
of the diseased conditions above described. 

Treatment. — On examining a case of stomatitis, not only the condi- 
tion of the mouth should be ascertained, but also of the digestive system, 
and in fact the whole body. When this has been done, the direct and 
remote causes should be sought out, and removed or corrected, as far as 
may be. If the exciting cause be a direct irritant it should be removed ; 
if from nursing, the child should be weaned ; if from the use of a mer- 
curial, it should be suspended ; and finally, if it be from filth, bad air, 
deficient or unwholesome food, &c, these unfavorable circumstances 
should be removed, and the patient be kept clean, allowed good air, 
and a proper amount of plain, digestible, and nourishing food, to be 
taken with regularity. Having thus removed or suspended the cause or 
causes that have been operating, attention should be directed to correct- 
ing the local disease of the mouth, and also the general condition of the 
system, upon which it depends. 

If the general disturbance consists merely in indigestion, with consti- 
pation or diarrhoea, with acidity, &c, the acidity should be corrected 
by small doses of prepared chalk, if there be diarrhoea, but with mag- 
nesia, if there be constipation. If, however, there be debility of the 
digestive organs, with poverty of the blood, small doses of the compound 
tincture of rhubarb, or of the fluid extract, may be given, with the infu- 
sion, or fluid extract of columbo, before each meal, to improve the diges- 
tion ; and to restore the blood, small doses of the ammoniated citrate of 
iron may be given after each meal, and continued for a time. If, how- 
ever, there be a scrofulous condition, the syrup of the iodide of iron 



STOMATITIS. 337 

may be given instead of the citrate, and, if the stomach will tolerate it, 
small doses of the cod liver oil, an hour after each meal, may help to 
supply nourishment for the system, without much labor of the digestive 
organs. 

If there is a general depraved condition of the system, and especially 
of the glandular system, or a syphilitic taint, or mercury in the system, 
the iodide of potassium may be indicated, and should be given, instead 
of, or with the vegetable bitter, before each meal, and continue for a 
long time. If other general morbid conditions exist, they should be 
corrected by proper remedies, judiciously applied ; and while this 
general treatment is being pursued, various local applications may be 
resorted to, for the purpose of correcting the local morbid condition of 
the mouth. 

In simple cases of sore mouth, a strong sage tea with alum, one or 
two drachms to half a pint, sweetened with honey or loaf sugar, may 
generally do very well, as a wash. 

In thrush, a strong decoction of the root of the geranium moculatum, 
with one or two drachms of borax, made sweet with honey or loaf sugar, 
and applied six or eight times per day, is an excellent application. Or 
if the fluid extract of the cranesbill be at hand, an ounce of it may be 
added to six ounces of water, and then the wash prepared with the 
borax and honey, or sugar, as directed above ; and applied several 
times per day. 

In aphtha, in the early stage, mucilage of gum arabic, with . a little 
laudanum, may be indicated, till the general inflammation of the mouth 
subsides, leaving only the ulcers, which may then be touched, carefully, 
with the nitrate of silver, in substance, taking care not to injure the 
surrounding parts. "In case, however, the ulcers are very numerous, in- 
stead of applying caustic, a saturated solution of alum, in simple syrup ; 
or water, accidulated with muriatic acid, and added to an equal part of 
honey, may be used as an application to the ulcerated surface. 

In ulcerative stomatitis, the alum in simple syrup, or the dilute mu- 
riatic acid, with honey, as directed in aphtha, should be applied at first, 
and if after continuing the application for a reasonable time, points of 
ulceration remain, the lunar caustic in substance, or in strong solution, 
may be applied to complete the cure. 

In cases of nursing sore-mouth a decoction of the petals of the red 
rose, made from two drachms of the petals, and half a pint of water, to 
which two drachms of borax, and two fluid drachms of laudanum should 
be added, will generally do well as a local application. In cases, how- 
ever, in which this fails, a solution of the nitrate of silver, two grains to 
the ounce of water may be used instead, till a cure is effected. 

In gangrenous stomatitis, as soon as the white or grayish surface ap- 
pears, the solid nitrate of silver may be applied, or, what may perhaps 
answer, the tincture of the chloride of iron. After the separation of the 
sloughs, a solution of alum, the decoction of peruvian bark, or the tinc- 
ture of myrrh may be applied, to promote the healing process. In mild 
cases of this affection, a solution of the chloride of soda (Labarraque's), 
diluted with eight parts of water, is a very valuable local application. 

In mercurial stomatitis, a strong decoction of the water-pepper, or 
22 



338 DISEASES OF THE DIGESTIVE SYSTEM. 

smart-weed (Polygonum punctatum), used as a wash, especially if there 
be general inflammation and swelling of the mouth, is a valuable remedy. 
Instead of the decoction, an ounce of the fluid extract may be diluted 
with seven ounces of water, and this may be used till the height of the 
inflammation is subdued, and then it may be continued with alum till a 
cure be effected. Thus have I completed what I had to say, on stoma- 
titis, in its various forms. 

SECTION II.— GLOSSITIS. 

By glossitis, from yx«tf*a, "tongue,' and itis, "inflammation," I mean 
here inflammation of the substance of the tongue, involving its muscular 
tissue. The tongue, it will be remembered, is composed of muscular 
fibres, distributed in layers, some longitudinal, others transverse, and 
others still oblique and vertical, between which there is considerable 
cellular tissue and adipose substance. The tongue, thus constituted, is 
liable to become inflamed, and when it does, from the nature of its struc- 
ture, it is apt to be rapid in its course, and to be attended with conside- 
rable swelling. 

It generally begins with a throbbing pain in the tongue, which is soon 
followed by redness and swelling. In a few hours, the whole tongue 
becomes involved in the inflammation, and a high state of general febrile 
excitement is developed. The swelling of the tongue increases rapidly, 
till it nearly fills the mouth, and is sometimes thrust out between the 
teeth. The respiration becomes extremely difficult, sometimes threaten- 
ing even suffocation, and deglutition becomes difficult, if not impossible, 
in bad cases at least. 

The tongue is generally of a darkish red color, and dry, though it may 
be moist, and covered with a reddish-yellow, or whitish fur. As the 
general febrile excitement becomes developed, the pulse is quick and 
strong, and the skin hot and dry ; but if the breathing becomes greatly 
embarrassed, the pulse has less strength, and cold sweats may occur. 
The inflammation may terminate in resolution, or it may pass on to sup- 
puration or gangrene. If suppuration takes place, one or several abscesses 
may form. If gangrene, only portions of the tongue may slough, and 
so a tolerable reparation of the loss takes place after the disease sub- 
sides. In some cases a permanent induration remains after the subsi- 
dence of the inflammation. 

Causes. — Inflammation of the tongue may occur by extension of the 
inflammation in tonsilitis, or it may arise in the exanthematous fevers, 
or from a mercurial course. 

Glossitis may also occur from atmospheric vicissitudes, but I believe 
it is most frequently produced by local irritating causes, such as acrid 
substances taken into the mouth, wounds, bruises, or the sting or bite of 
venomous insects, &c. 

Treatment. — Immediately on the appearance of inflammation of the 

tongue, the patient should have his feet placed in warm water, and if the 

patient be of a sthenic constitution, blood may be taken from the arm, 

and then cups applied to the back of the neck, and leeches along the 

-margin of the lower jaw, if they are at hand. If leeches are not to be 



PHARYNGITIS. 339 

had, and the inflammation and swelling are very great, incisions may be 
made into the tongue from the base to the tip, on each side of the me- 
dian line, care being taken not to wound the ranular arteries. 

The warm foot-bath may be used, morning and evening, and imme- 
diately after the general bleeding, if the patient can swallow, a tea- 
spoonful of the fluid extract of senna should be administered, with half 
an ounce of the sulphate of magnesia, and the dose repeated in four or 
six hours if necessary. In case the patient is unable to swallow, the 
bowels should be kept loose by enemata, and should suffocation be threat- 
ened, the larynx or trachea should be laid open at once. 

SECTION in.— PHARYNGITIS— {Sore-throat.) 

By pharyngitis, from $apuyi, "pharynx," and itis, "inflammation", I 
mean inflammation of the mucous membrane of the pharynx ; whether 
simple or ulcerative ; acute or chronic. 

The pharynx is the musculo-membranous canal, situated between the 
base of the cranium and the oesophagus, and in front of the vertebral 
column. It is formed externally by a muscular coat, and internally by 
a mucous membrane which is continuous above with the schneiderian 
membrane ; in the middle, with that of the mouth, and below with the 
mucous membrane of the oesophagus. 

The pharynx is a common origin of the digestive and respiratory 
passages, giving passage to the air in respiration, and to the food in 
deglutition, and is more or less liable to become inflamed. Inflammation 
of the mucous membrane of the pharynx may be acute or chronic ; 
simple or ulcerative. It may involve only the superior portion of the 
pharynx, or it may extend down to the oesophagus. 

Symptoms. — Simple inflammation of the mucous membrane of the 
pharynx is first noticed by a feeling of dryness in. the throat, and more 
or less pain in swallowing. Soon the fauces assume a red color, become 
swelled, and finally, present white patches of lymph, which is thrown 
out by the inflamed follicles. The dryness and heat of the throat 
increase, and the pain becomes intolerable, if an attempt be made to 
swallow. The voice becomes hoarse, a viscid mucus collects in the 
throat, and slight febrile excitement follows, with loss of appetite, head- 
ache, a dry skin, frequent pulse, &c. The inflammation generally 
terminates by resolution in a few days, but it may gradually extend to 
the schneiderian membrane, eustachian tube, or larynx, and the inflam- 
mation assume a chronic form. 

When inflammation of the pharyngeal mucous membrane assumes a 
chronic form, it may continue for a long time, being attended with heat, 
redness, &c. ; the membrane being thickened, and the mucous glandules 
enlarged, presenting eminences in different parts of the pharynx. A 
muco-purulent secretion collects in the fauces, ulceration sometimes takes 
place either superficial or involving the tissues beneath the mucous mem- 
brane, especially if there be a depraved condition of the system ; and 
finally, unless the disease be arrested, the uvula becomes enlarged, the 
hearing indistinct, and the patient is tormented with a distressing laryn- 
geal cough. 



340 DISEASES OF THE DIGESTIVE SYSTEM. 

Pseudo-membranous inflammation of the pharynx sometimes occurs, 
being characterized by the exudation under the epithelium of fibrinous 
matter. This form of pharyngitis commences with the ordinary symp- 
toms of mild sore throat. Soon, however, the fibrinous exudation com- 
mences, exhibiting, irregular patches, of a whitish or gray appearance, 
extending, more or less over the pharynx. This exudation under the 
epithelium is of the character of false membrane, presenting under the 
microscope, according to Professor Wood, " interlacing fibrils, molecular 
granules, epithelial cells in different stages, and often pus or blood cor- 
puscles."* In severe cases of this affection, the exudation may extend 
till it covers the whole pharynx ; and it may extend into the larynx, and 
even along the trachea to the bronchia, obstructing respiration, and 
leading to the most disastrous results. This exudation may finally be 
absorbed, or it may soften and become mingled with the fluids of the 
mouth, the surface being covered with a viscid puriform mucus mingled 
with more or less blood, which keeps up a constant hawking and spitting, 
with more or less cough. 

This variety of pharyngitis is evidently connected with a deranged 
condition of the system, and especially with an abnormal state of the 
blood. It may be mild, terminating favorably in two or three weeks ; 
or it may extend, as we have seen, assume a malignant form, and lead 
to the most serious results. 

An ulceration or gangrene may occur in any form of inflammation of 
the mucous membrane of the pharynx, or either of these conditions may 
occur very early, so as to constitute a primary feature of the pharyngeal 
affection. 

"When ulceration occurs, either as a primary or secondary affection, 
there is a sharp, pricking sensation, in addition to the ordinary symp- 
toms of sore throat; and on looking into the fauces, one or more oval 
spots of ulceration, at first white, but later excavated and red, are dis- 
covered. If the derangement of the system upon which the ulceration 
depends, be corrected, these excavated points may speedily fill up, and 
cicatrize. But if the derangement continue, the ulceration may not 
only continue, but spread more or less extensively. 

When gangrene occurs in simple or pseudo-membranous pharyngitis, 
or as an apparent original affection, it may involve only the mucous 
membrane, or it may extend to the structure beneath ; more or less ex- 
tensive sloughs being formed. I believe that in all primary or secondary 
gangrenous affections of this character, there is a pre-existing state of 
the system, and especially of the blood, which leads to the mortification 
which occurs. 

The symptoms attending this gangrenous condition, including the 
general inflammatory symptoms, the gray or darkish slough, and the 
irregular depressions which they leave together with the fetid breath, 
are sufficiently indicative of the destructive processes which are going on. 

Diagnosis. — There is no difficulty in distinguishing simple pharyngitis, 
or even the pseudo-membranous, if the parts be carefully examined. 
When ulceration or gangrene occurs in either variety, or as original 
affections, a careful observation of all the symptoms, will enable the 

*See Wood's Practice of Medicine, vol. i. p. 551. 



PHARYNGITIS. 341 

acute observer to get at the real condition, which should always be the 
point aimed at in making an examination in any case. 

Causes. — The most frequent causes of simple mucous pharyngitis are, 
according to my observation, damp air, atmospheric vicissitudes, furs 
worn about the neck, the use of tobacco, drinking hot tea or coffee, 
acrid eructations from the stomach, gastro-intestinal irritation, wet feet, 
and finally living or sleeping in low damp apartments. 

Now any one or all these causes may operate to produce pseudo- 
membranous pharyngitis in patients whose constitution, and especially 
abnormal state of the blood, predispose to the fibrinous exudation which 
occurs in such cases. And if there is, in addition to this condition, the 
debility arising from hunger, unwholesome food, and various abuses of 
the system, we may have ulceration or even gangrene supervening or 
even occurring apparently, as the primary affection. 

Treatment. — In simple pharyngitis, it may be sufficient to remove the 
cause which has been operating, whatever it may be ; to give a full 
dose of the sulphate of magnesia, to direct the warm foot bath at evening 
for two or three nights, and to have the throat gargled, three or four 
times per day with a strong sage tea made sweet with honey or sugar, 
and containing in solution alum, one or two drachms to the half pint. 

If, however, the inflammation assume a chronic form, or be so from 
the first, the general condition of the system should be inquired into, 
and especially that of the digestive system ; and the general health cor- 
rected by a regulated diet, and by such remedies as are clearly indicated, 
at least as far as it may be. If there be acidity of the stomach with 
constipation, a teaspoonful of magnesia may be given each morning, but 
if diarrhoea attend, a little prepared chalk may be given after each meal 
and a pill of aloes and rhubarb at evening, each day, till the constipa- 
tion is corrected. 

While this general condition is being corrected in the early stages, 
astringent applications may be of service. If there be a general relaxed 
condition of the mucous membrane, with only a moderate degree of 
tenderness, a strong solution of tannin, a drachm to half a pint of water 
will do very well as a gargle after each meal. Or if the patient be a 
child, an ounce of the fluid extract of cranesbill may be added to eight 
ounces of water and sweetened with honey or loaf sugar, and used 
instead. 

As the relaxed condition of the pharyngeal mucous membrane is thus 
corrected, if there remains some tenderness, a fine powder made of 
equal parts of alum and loaf sugar may be dropped into the throat each 
night on retiring to bed. The head may be held back, and two or three 
pinches of the powder dropped carefully into the fauces, and as it 
gradually dissolves it passes down, and thus comes into contact with the 
mucous surface in the lower portion of the pharynx. 

After the general condition of the system is corrected, if the astrin- 
gent applications have failed in effecting a cure of the local difficulty, a 
strong solution of the iodide of potassium, or nitrate of silver, should be 
applied to the fauces, with a camel's-hair pencil, once each day, and 
continued till the local morbid condition is corrected. If there be only 
soreness, without much thickening of the mucous membrane, the nitrate 



342 DISEASES OF THE DIGESTIVE SYSTEM. 

of silver may do best, of the strength of thirty or forty grains to the 
ounce of water, or even stronger. But in cases in which there is thick- 
ening of the mucous membrane, with an edematous state of the tissues 
beneath, the iodide of potassium will generally do best, of the strength 
of three or four drachms to the ounce of water. 

In cases of acute pharyngitis, in which there is considerable swelling, 
without very much tenderness of the throat ; and in chronic cases, in 
which there is a viscid secretion, and the astringent and caustic applica- 
tions are not indicated, or appear to disagree, a solution of the muriate 
of ammonia, in vinegar and water, will do very well. Two drachms of 
the muriate of ammonia may be dissolved in half a pint of vinegar and 
water, four fluid ounces of each, and used as a gargle, morning and 
evening. 

In pseudo-membranous pharyngitis the general condition should be 
corrected, depletion being resorted to, with mercurials, if the system be 
in a sthenic condition ; and tonics, with the iodide of potassium, if the 
system be in a debilitated or asthenic state. 

While the general condition is being thus corrected, and the extension 
of the disease to the larynx carefully guarded against, fifteen or twenty 
grains of the sulphate of zinc to a fluid ounce of water may be applied, 
twice each day, to the pseudo-membranous patches, by means of a 
camel's-hair pencil. In case the zinc should prove ineflicient, either 
the undiluted muriatic acid, or solid nitrate of silver may be used in- 
stead, and continued till a cure is effected ; mucilaginous gargles, sweet- 
ened with honey or sugar, being used between the caustic applications. 

In cases in which ulceration or gangrene occur, the general condition 
should be corrected by the iodide of potassium, iron, quinine, a regu- 
lated diet, &c, and the ulcers touched daily with a solution of the 
nitrate of silver, twenty grains to the fluid ounce, till their surface 
becomes red, when they will generally heal, as will gangrenous depres- 
sions, as the general condition is corrected, and the sloughs removed. 

SECTION IV.— TONSILLITIS— ( Quinsy.) 

By tonsillitis, I mean here inflammation of the substance of the ton- 
sils, which it will be remembered, are two glandular organs, situated 
between the anterior, and posterior pillar of the soft palate, on each side 
of the fauces. They are composed of an assemblage of mucous follicles, 
which open through the mucous membrane, which lines their inner sur- 
face, and pour out a transparent viscid mucus, which lubricates the 
fauces, and favors deglutition. 

The tonsils, thus situated, are quite liable to become inflamed, either 
one or both ; but more generally both, I believe, and the inflammation is of 
a phlegmonous character. In our climate, quinsy is very common, and 
though in general not a dangerous disease, may under certain circum- 
stances, assume a malignant character. 

Symptoms. — The disease generally begins with slight chills, succeeded 
by a high grade of febrile excitement, attended with an uneasy feeling 
in the throat, and some uneasiness in swallowing. Generally in a few 
hours, the uneasiness in the throat or tonsils becomes very marked, and 



TONSILLITIS. 343 

deglutition more painful, till at last it becomes extremely difficult or im- 
possible. On examination of the throat, one or both tonsils are found 
swelled, and generally the whole fauces somewhat red and tumefied. The 
tongue is also sometimes slightly swelled, and covered generally with a 
thick layer of transparent mucus. 

The face is red ; the carotids beat strongly ; respiration is difficult ; 
the hearing obtuse ; the pulse frequent, hard and full ; and generally 
the voice is indistinct. The pain shoots into the ears, if the patient at- 
tempts to speak, the mouth being opened with great difficulty. A thick 
ropy mucus adheres to the inflamed parts, which very much increases the 
difficulty of respiration. 

When both tonsils become inflamed, they frequently nearly fill the 
throat ; the uvula and soft palate being generally more or less swelled. 
The external part of the throat, in the region of the tonsils, is gener- 
ally more or less swelled, and tender to the touch. This inflammation 
generally terminates in resolution or suppuration ; and not unfrequently 
will abscesses form in a few days, especially if neglected during the 
early stages. These abscesses usually point internally ; but sometimes 
they point externally, under the angle of the jaw. Frequent attacks of 
this inflammation, generally produce more or less permanent enlarge- 
ment, or induration of the tonsils. 

Causes. — Some individuals appear strongly predisposed to tonsillitis ; 
but other things being equal, persons of a strumous diathesis, are most 
liable to this affection. The disease is much more liable to occur in damp 
changeable weather, than when the air is dry, either warm or cold. 
Among the exciting causes, sudden exposure to cold, or standing long 
on cold wet ground, or ice, by checking the perspiration, will frequently 
produce tonsillitis, in those who are predisposed. 

Treatment. — At the very commencement of this affection, warm 
drinks of sage tea, and a warm pediluvium will be of essential service ; 
and sometimes by restoring the perspiration, may arrest the disease. 
But if, as generally happens, the fever and local inflammation continue, 
cups should be applied to the back of the neck, and a brisk cathartic ad- 
ministered. Half an ounce of the sulphate of magnesia, with a drachm 
of the fluid extract of senna may be administered at once, and repeated 
in six hours, if necessary. 

To allay the general febrile excitement, promote perspiration, &c, 
one-eighth of a grain of tartar emetic, or one-fourth of a grain of ipecac, 
or five drops of the fluid extract, with four or five drops of the fluid extract 
of the veratrum viridi may be administered every four hours, the warm 
foot bath being used morning and evening. As a gargle, half an ounce 
of the muriate of ammonia, dissolved in half a pint of vinegar and water, 
four fluid ounces of each, to which two drachms of laudanum may be 
added, will do well in all stages of the inflammation, and may be used 
every four or six hours. Sinapisms in the early stage, with fomentations 
of hops wet in warm vinegar, may be of essential service, if applied over 
the region of the tonsils, but later, blisters may become necessary. 

If however, as sometimes happens, abscesses form, an early evacuation 
of the matter should be sought, by a free opening in the most prominent 
part, care being taken not to reach the carotid artery with the instru- 



344 DISEASES OF THE DIGESTIVE SYSTEM. 

nient. A mild unstimulating diet should be directed for several days, and 
every possible exciting cause of this affection should be carefully avoided. 
In cases of tonsillitis that assume a malignant or typhoid character, 
quinine, wine-whey, and animal broths may become necessary, and thus 
the system be sustained till the local affection subsides. 

SECTION V.— PAROTITIS— [Mumps.) 

By parotitis, I mean inflammation of the parotid gland. This gland 
named from its position, yiapa, "about", and ov$ "the ear," is the largest of 
the salivary glands, and situated in front of the external ear. It is 
composed of many separate lobes with excretory ducts, which unite to 
form Stenon canal. This canal passes forward horizontally and termi- 
nates in the mouth, opposite the second upper molar teeth. The parotid 
glands secrete saliva, which is poured through this duct into the mouth, 
to moisten the food as it is masticated. 

The parotid glands thus situated, are liable to a specific inflammatory 
affection, capable of being propagated by contagion. 

Symptoms. — Parotitis usually commences with slight febrile symptoms, 
a stiffness of the jaws, and a slight pain and swelling in one or both 
parotid glands. The swelling generally gradually increases till the end of 
the third or fourth day from the beginning of the disease, at which time 
the glands are usually considerably swelled, and tender to the touch. 
The skin generally remains nearly of its natural color over the inflamed 
part, but sometimes it is slightly red. 

Mastication and deglutition are generally attended with considerable 
pain. And though there is only a mild fever it is often attended with 
considerable nervous irritability and restlessness. From about the 
fourth day of the disease, the swelling, tenderness, and fever gradually 
decline, disappearing entirely by about the seventh day, and being 
succeeded by perspiration about the face, and sometimes over the whole 
body. 

After the swelling of the parotids begin to decline, and the inflamma- 
tion to abate, the breast in females, and the testicles in males, are liable 
to become painful and swelled. Or metastasis to the brain, or its me- 
ninges, may suddenly occur, and even endanger life. In cases in which 
the testicles become inflamed, the affection becomes very tedious, and I 
have known the most violent acute gastritis to occur from a translation 
of this disease. Children and young persons are more liable to paro- 
titis than persons of more advanced age, and it generally occurs but 
once in the same individual, resembling, in this respect, other contagious 
diseases. 

Causes. — It is probable that a specific contagion is the most frequent 
cause of mumps, but I suspect that it may originate from endemic or 
epidemic influences, independent of contagion, as the disease arises, in 
some instances, under circumstances favoring this supposition. In cases, 
however, in which mumps do thus arise, if such be a fact, it appears to 
be as contagious as when contracted in the usual way. 

Treatment. — Mild cases of parotitis require little more than for the 
parts to be kept warm, and for the patient to avoid cool or damp air, 



OESOPHAGITIS. 345 

and to take a plain digestible diet. If there be constipation of the 
bowels, a seidlitz powder may be given, or a drachm of the fluid extract 
of rhubarb, with half an ounce of the sulphate of magnesia. 

If, however, the inflammatory symptoms run high, ten grains of 
calomel, or two grains of podophyllin may be given, in half an ounce of 
castor oil, and the oil repeated in five or six hours, if necessary. Tartar 
emetic may be given in one-eighth of a grain doses, with five drops of the 
fluid extract of ipecac, every four or six hours, and if the arterial action 
be very considerable, three or four drops of the fluid extract of the 
veratrum viridi may be added to each dose. 

When the inflammation is translated to the breast, or testicles, the 
same general treatment should be continued, and sinapisms, or if neces- 
sary, a blister applied to the parotids. A warm hop poultice should be 
applied to the inflamed testicle or breast. Should the translation of the 
inflammation be to the stomach or brain, a blister should be applied to 
the parotid, and a warm hop poultice be kept to the sides of the face. 
If the brain be the seat of the inflammation which is set up, the head 
should be elevated, and the feet placed in warm water, and cups, and 
then blisters, applied to the back of the neck. The tartar emetic, ipecac 
and veratum should be continued, and, if necessary, alterative doses of 
calomel given every four or six hours, till the cephalic inflammation is 
subdued. 

Should the translation of the inflammation be to the stomach, as hap- 
pened in one case under my care, after applying a blister to the paro- 
tids, as I have suggested, cups, wet or dry, may be applied on each side 
of the spine, opposite the stomach, or to the epigastrium, and a warm 
hop poultice applied to the epigastrium. The violent vomiting may be 
arrested, in such cases, by giving a grain of Dover's powder, with one 
fourth of a grain of calomel every fifteen minutes, after which, ten 
drops of the fluid extract of hyoscyamus may be given, with mucilages, 
every six hours, but on no account should blisters, or even mustard be 
applied to the epigastrium in such cases. 

SECTION VI.— OESOPHAGITIS. 

By oesophagitis, I mean inflammation of the oesophagus, which is that 
portion of the alimentary canal extending from the pharynx to the sto- 
mach, passing behind the trachea, along the posterior mediastinum, and 
into the abdomen through the oesophageal opening in the diaphragm. 

The oesophagus, it will be remembered, from otw, "I carry," and 4>ay«, 
"I eat," conveys the food from the mouth or pharynx to the stomach, 
for which purpose it is provided with longitudinal and annular muscular 
fibres, its lining mucous membrane being continuous above, with that of 
the pharynx, and below with the mucous membrane of the stomach. 
The oesophagus, thus constituted, is liable to become inflamed; the in- 
flammation, in some cases, being confined to its mucous lining membrane, 
but in others, extending to its muscular structure. 

Symptoms. — Inflammation of the oesophagus is attended with heat and 
pain, more or less aggravated by swallowing, at some point along the 
tube, but generally referred either to its upper or lower extremity. 



346 DISEASES OF THE DIGESTIVE SYSTEM. 

There may be pain between the shoulders, and perhaps tenderness on 
pressure, with more or less difficulty in swallowing. There is generally 
little or no fever, but there may be hiccough, and perhaps nausea and 
vomiting. 

The inflammation generally terminates by resolution, but suppuration 
may take place, small abscesses forming in the submucous cellular tissue. 
Ulcers may form, or a pseudo-membrane may extend from the pharynx, 
along more or less of the oesophagus. (Esophagitis is generally of an 
acute character, but it may assume a chronic form. 

Causes. — This disease may be an extension of inflammation, either 
from the pharynx or stomach ; or it may be the result of retrocession of 
various cutaneous affections ; but generally it is the result of mechanical 
violence, or of some acrid, corrosive, or hot substance swallowed. 

Treatment. — The indications in the treatment of this disease, may 
best be fulfilled, by warm pediluvia, morning and evening ; cupping to 
the back of the neck, and leeches along its side, over the oesophagus ; 
saline cathartics; a liquid farinaceous diet; and should the disease 
become chronic, blisters may be applied, and mercury or iodide of potas- 
sium given internally. 

SECTION VII.— ACUTE GASTRITIS. 

By acute gastritis, I mean here an acute inflammation of the stomach, 
involving essentially its mucous membrane ; but extending, in many cases, 
to the muscular, and even peritoneal coats. The stomach, it will be re- 
membered, is an expansion of the alimentary canal, situated beneath the 
diaphragm, between the liver and spleen; occupying the epigastrium, 
and a portion of the left hypochondrium. The stomach has a mucous, 
muscular, and serous coat, and is continuous above with the oesophagus, 
and below with the duodenum; and is that portion of the alimentary 
canal, in which the food is converted into chyme. 

The stomach is liable to become inflamed, in all its coats; but its 
mucous membrane, which is a continuation of the skin, passing inward 
to line the alimentary canal, is especially so. This membrane in the 
stomach, is well supplied with arteries, veins, and nerves ; but its struc- 
ture being loose, its inflammation is not necessarily attended with any 
considerable pain, and what there is, may be of a biting, stinging 
character. 

Symptoms. — The symptoms of acute inflammation of the mucous 
membrane of the stomach, involving more or less, its submucous cellular 
tissue, and in some cases its muscular coat, and perhaps peritoneal, are 
just what we should suppose from the nature of the structures involved. 

Acute gastritis generally commences with violent vomiting, and some- 
times purging, attended with a burning stinging pain in the stomach. 
The vomiting is generally increased by the swallowing of warm liquids ; 
but cool drinks may produce a transient alleviation. If the inflammation 
be severe and general, extending to the submucous cellular tissue, and 
muscular coat of the stomach, the respiration becomes anxious and diffi- 
cult, as the diaphragm does not descend to produce free expansion of the 
lungs. 



ACUTE GASTRITIS. 347 

There is in such cases, tenderness on pressure, an increase of pain on 
making a deep inspiration, and also in the act of vomiting. The sub- 
stances thrown from the stomach, consist first of the food, and later of 
mucus, bile, and in some instances a tinge of blood. The thirst is urgent, 
and the tongue is either red, dry, and smooth, without fur; or else it is 
covered in the middle and posterior part, with a white fur, its tip and 
edges being red ; the papilhe being prominent through the coating, and 
of a deep red appearance. 

The brain sympathizes w T ith the stomach, producing in some cases, 
more or less delirium, and there is great depression of spirits and pros- 
tration of strength. The pulse, at first moderately full, becomes con- 
tracted, quick, and tense, and finally so small as scarcely to be felt. A 
short, sympathetic cough generally attends, and the voice may become 
altered, and sometimes nearly extinct. If the inflammation be confined 
to the stomach, the bowels are constipated; but if they participate in 
the inflammation, there is a diarrhoea and perhaps dysenteric discharges. 

If the disease tends to a favorable termination, the vomiting gradually 
abates, the tongue becomes moist, the pulse fuller and less frequent, the 
skin becomes moist and soft, and finally, convalescence is fully estab- 
lished. But should the disease tend to a fatal termination, the tongue 
becomes more dry, the skin cold and pale, the pulse feeble and thread- 
like, the patient becomes restless and delirious, dark matter is ejected 
from the stomach, the countenance becomes cadaverous, and finally the 
extremities become cold, and the patient dies from extreme exhaustion. 
Or if perforation of the stomach takes place, the pain increases and be- 
comes diffused; the whole abdomen becomes painful and tender, and 
each breath is attended with a groan ; the patient passing on speedily 
to dissolution. 

Gastritis may assume a much milder form, being attended with little 
pain or tenderness, and continuing for several weeks, while violent cases 
may terminate in one or two days, especially if some irritating poison 
has been the cause of the inflammation. In cases of acute gastritis, in 
which there is little or no pain or tenderness, and only sympathetic dis- 
turbance of the brain and other portions of the body, darting pains in 
the chest, &c, it is probable that the inflammation is confined almost 
exclusively to the mucous membrane ; and hence the absence of pain, 
and in fact, of most other symptoms which are usually developed in 
gastritis. 

Anatomical Characters. — On post-mortem examination of the stomach, 
it is found contracted, and its mucous membrane more or less wrinkled. 
In violent cases, where death has occurred suddenly, in the early stages, 
there is generally discoloration, with but slight ulceration of the mucous 
membrane. But in cases that prove fatal at a later stage of the disease, 
there is ecchymosis and ulceration, and some portion of the membrane 
is in a softened and broken down state, and appears of a red, yellowish, 
or dark brown color. 

Diagnosis. — Acute gastritis may generally be distinguished from 
cramp and flatulent pains, by attention to the following facts : In gas- 
tritis, the pulse is small, tense and quick; while in spasm or flatulent 
pains, there is seldom vomiting, and warm drinks produce no unpleasant 



348 DISEASES OF THE DIGESTIVE SYSTEM. 

effects. The pain is continuous in gastritis, unless it be temporarily allevi- 
ated by cool drinks, while in spasm the pain frequently intermits for several 
minutes. In gastritis, the patient lies on his back, and moves as little as 
possible ; while in cramp, he walks about with the body bent forward, 
or throws himself about on the bed. 

In gastritis the skin is hot and dry, and the pain of a burning, sting- 
ing character, while in spasm the skin remains nearly natural, and the 
pain is sharp, cutting and extremely severe. Finally pressure over the 
stomach in gastritis is attended with some degree of soreness, and an 
increase of pain, while in cramp, pressure generally affords some relief. 

Causes. — Various causes may operate in producing acute gastritis, 
among the most frequent of which, are acrid substances received into 
the stomach, cold water taken whem the body is heated, over-distension 
of the stomach by indigestible food, stimulating drinks, suppression of 
habitual sanguineous discharges, metastasis of parotitis, erysipelas, or 
rheumatism, and finally, mechanical injuries of the epigastrium. It is 
possible also, that Jcoino and idio-miasmata by entering the stomach with 
the saliva, or by passing to its mucous membrane through the blood, 
may produce acute gastritis, but this is not quite certain. 

Prognosis. — A gradual subsidence of the pain and vomiting, a sedi- 
mentous urine, a gentle moisture of the skin, and a more developed 
pulse, indicate a favorable termination. If, however, the vomiting 
continue with difficult respiration, and hiccough, the pulse becomes 
smaller, more frequent, and corded, and finally, the pain suddenly sub- 
sides, the extremities become cold, with dimness of sight, and delirium, 
a fatal termination is inevitable. 

Treatment. — In the incipient stage of acute gastritis, warm pediluvia, 
with warm stimulating friction along the spine, and sinapisms to the 
epigastrium, together with cool mucilaginous drinks, may at once arrest 
the disease. If, however, the patient has been neglected, or we do not 
succeed in arresting the disease by these mild measures, cups or leeches 
should be applied to the epigastrium, and cups on each side of the 
spine, opposite the stomach, and from two to four ounces of blood taken, 
and after the cupping, a blister may be applied to the epigastrium. 

The bowels should be moved by an injection of castor oil, in flaxseed 
tea, or in equal parts of milk and water. And to allay the nausea, 
stop the pain and arrest the vomiting, one fourth of a grain of calomel, 
with a grain of Dover's powder should be given every hour, till these 
unpleasant symptoms subside, and cool mucilages freely allowed as the 
only drink or nourishment during the acute inflammatory stage. 

In cases in which some active poison has been taken, the whites of 
half a dozen eggs may be swallowed, and the whole contents of the 
stomach thrown off by a full dose of ipecac, administered in mucilage of 
gum-arabic. After free vomiting has been produced in such cases, 
proper antidotes should be administered for neutralizing the poison, 
should any still remain, and if no diarrhoea attend, small doses of 
calcined magnesia, or castor oil, may be given to remove any of the 
poison which may have accumulated along the intestines. 

Having thus cleared the stomach by the emetic, and the intestines by 
a laxative, and neutralized as far as may be, the poison in the system, 



CHRONIC GASTRITIS. 349 

as well as counteracted its affects, the case should be treated according 
to the principles I have already laid down, modified of course to meet 
aiiv peculiarity the case may present. In the early stage of acute 
gastritis, no food except mucilage should be allowed, a little later, arrow- 
root and rice may be taken, and gradually other mild varieties of 
digestible food. 

SECTION VIII.— CHRONIC GASTRITIS. 

By chronic gastritis I here mean to include all cases of inflamma- 
tion of the stomach, not of an acute character ; though many cases of 
chronic gastritis are the result of the acute form of the disease. 

When we take into account the great variety of abuse to which the 
stomach is liable, from irritating and unwholesome articles of food and 
drink, and its variety of sympathetic relations, we need not wonder that 
this is one of the most frequent of the phlegmasical affections. The 
slow and insidious progress of this grade of gastric inflammation, espe- 
cially during its early stages, is probably the reason why there is so 
frequently a misapprehension as to its true character. 

Symptoms. — In chronic gastritis, not the result of the acute form of 
the disease, the affection generally approaches very slowly and insidi- 
ously, so that it has often progressed considerable before it receives 
particular attention. The early symptoms of chronic gastritis are those 
that usually characterize indigestion, such as acidity, flatulence, a sense 
of oppression after eating, eructations, and transient pain in the region 
of the stomach. 

The patient may feel comfortable when the stomach is empty, only 
there is apt to be a languid dissatisfied craving or appetite for food. 
As the disease progresses the epigastrium becomes slightly distended, 
and tender to the touch, and nausea, and sometimes vomiting occurs an 
hour or two after eating. The gastric distress gradually becomes more 
troublesome, especially after eating, the pain in the stomach being con- 
fined to a circumscribed spot, and of a lancinating character. The 
patient frequently complains of feeling as if a heavy substance were 
lodged in the stomach, and pressing against the diaphragm. 

In some cases there is a thick ropy substance raised from the stomach, 
while in others there is thrown up an acrid, sour, watery, liquid, espe- 
cially after eating. In the latter stages of the disease the appetite 
generally fails ; and in very aggravated cases the patients even loathe 
food. 

In the early stages of the disease the bowels are apt to be constipated, 
but later there is generally a diarrhoea, at least a portion of the time. 
The patient becomes dejected, impatient, acquires an irritable temper, 
and is frequently even indisposed to give an account of his sufferings. 
The tongue is generally red and granulated, or covered with small red 
points, or there may be a streak of brown fur along the middle, the 
edges being red and clean. 

In protracted cases of the disease emaciation goes on rapidly, the 
adipose structures becoming sometimes almost entirely absorbed. The 
skin becomes dry, and of a yellowish-brown color, and is drawn tightly 



350 DISEASES OF THE DIGESTIVE SYSTEM. 

over the muscles, giving the surface a rough or rigid appearance. The 
pulse may be nearly natural, or quick and tense, in the early stages ; 
but later, it is apt to become irregular, contracted, hard, and frequent- 
There is generally much prostration, and great indisposition to bodily 
and mental exertion. 

The disease may continue for months, till the system becomes worn 
down and debilitated, and the patient dies from exhaustion ; or a sud- 
den perforation of the stomach or doudenum may occur, and the patient 
die of acute general peritoneal inflammation, as has happened in one or 
two cases that have fallen under my observation. 

When perforation occurs, the patient may scream out with an acute 
pain in the region of the stomach, which, however, gradually extends 
through the whole abdomen. Every breath is attended with a groan, 
warm drinks produce a general sensation of heat through the abdomen, 
and after a slight arterial reaction, the pulse and general system sink, 
and the patient dies, according to my observation, within twenty-four 
hours after the perforation. 

Anatomical Characters. — The inflamed portions of the mucous mem- 
brane exhibit either a red, gray, brown or blackish color. Or sometimes 
minute black points are seen, giving the surface a dark or grayish 
appearance. In some cases white patches are found, and the mucous 
coat may be thickened in spots or to a considerable extent, and it may 
present a granulated appearance, either from an enlargement of the 
gastric glands, or from an exudation into the tissue of the membrane. 

The membrane may be indurated, softened or ulcerated, the ulcers 
penetrating, in some cases, the muscular and even the peritoneal coat. 
If perforation has taken place, the edges of the orifice may be rough ; 
but in one case which I examined, it was circular, perfectly smooth, and 
the size of a half-dime, except in the serous membrane in which it was 
irregular. 

In cases in which perforation has taken place during life, and the con- 
tents of the stomach have escaped into the cavity of the abdomen, the 
peritoneum presents signs of having been very generally inflamed. 

Diagnosis. — Chronic gastritis may be confounded with dyspepsia, 
gastralgia and cancer of the stomach, from all of which affections, 
however, it may generally be distinguished by careful attention to the 
following differences. From dyspepsia it differs in there being more 
pain at some particular point ; more frequent vomiting after taking food, 
more redness of the tongue, and finally more weakness and general 
emaciation, than attends in simple dyspepsia. 

From gastralgia chronic gastritis differs by the pain being more con- 
tinuous and of a stinging character ; the tongue is more dry, and either 
coated or red, the appetite is more invariably bad, and in gastritis there 
is tenderness on pressure, and generally a frequent pulse, hot or dry 
skin, a sallow countenance and general emaciation, which symptoms do 
not generally exist to so great a degree in simple dyspepsia unattended 
with gastritis. 

From cancer of the stomach, chronic gastritis differs in there being no 
tumor in the region of the stomach ; in the* matter vomited being gene- 
rally of a less viscid or ropy appearance, in the dry, red, or coated ap- 



CANCER OF THE STOMACH. 351 

pearance of the tongue, and finally in the absence of the cancerous 
diathesis, and the more rapid termination of the inflammatory than of 
the cancerous affection. 

Causes. — Chronic gastritis is sometimes the result of the acute form 
of the disease, but it is generally produced by irritating substances 
acting on the mucous coat of the stomach ; such as heating or indiges- 
tible articles of food, acrid medicinal substances, as capsicum, &c. ; 
mental despondency, alcoholic liquors, and repelled cutaneous eruptions. 
And besides, chronic gastritis may arise from congestion of the portal 
circulation, or it may attend phthisis, with which affection it is a very 
frequent complication in its latter stages, and sometimes even from the 
commencement. 

Prognosis. — The prognosis in chronic gastritis is generally favorable 
if proper treatment be resorted to in season. But if the case be neglected, 
and the imprudence which has led to it is continued, ulceration, and 
finally perforation may occur, and thus the case terminate fatally. 

Treatment. — The first indication in the treatment of chronic gastritis 
is to remove the cause which has been operating to produce it, and to 
regulate the diet, allowing just that kind of food that is proper, and no- 
thing more. Early in the disease, mucilages, with arrow-root, boiled in 
milk, or milk and water, may be the only food allowed. Later, how- 
ever, when the inflammation is in a measure subdued, a poached egg, 
boiled milk, and gradually plain digestible varieties of food may be 
allowed, to be taken with strict regularity. 

Cups or leeches should be applied to the epigastrium, and repeated, if 
necessary, every t\* o or three days, at first. After the cupping or leech- 
ing has been continued as long as is consistent with the general condi- 
tion of the system, a blister should be applied to the epigastrium, and as 
it heals another should be applied, and this should be continued till the 
inflammation is subdued, the blisters being repeated at reasonable inter- 
vals. 

Having removed the cause, regulated the diet, and applied cups or 
leeches, and thus in a measure subdued the inflammation, a little may 
be done by way of medicine internally, if necessary. If the bowels are 
constipated, a teaspoonful of calcined magnesia may be given each morn- 
ing, till they are regulated, and this will also correct the acidity, which 
is often so troublesome in such cases. If, however, there is diarrhoea, 
the acidity may be corrected by small doses of prepared chalk, or lime- 
water, taken before each meal. 

As an astringent, anodyne, and tonic, a pill made of one grain, each, 
of the sulphate of iron, extract of gentain, and extract of conium or 
hyoscyamus may be given after each meal, and continued with a regu- 
lated diet till the disease is subdued. If, however, evidence of ulcera- 
tion should supervene, the pills may be prepared with one fourth of a 
grain of the nitrate of silver, instead of the sulphate of iron, and given 
instead. 

SECTION IX.— CANCER OF THE STOMACH. 

By cancer of the stomach, I mean that variety of malignant disease, 
attended with the formation of a scirrhous livid tumor, which finally 



352 DISEASES OF THE DIGESTIVE SYSTEM. 

ulcerates. The stomach is liable to this cancerous affection, which may 
locate in any portion of its structure, but generally in either the cardiac 
or pyloric extremity, and of the cases that have fallen under my obser- 
vation, the pylorus has generally been the part involved. Cancer of the 
stomach may, however, be of a scirrhus, encephaloid or colloid character, 
and it may pass on rapidly, and terminate in a few months, or it may 
continue to progress steadily for several years, and then terminate 
fatally. 

Symptoms. — The early symptoms of cancer of the stomach are gene- 
rally very similar to those of chronic gastritis ; there is uneasiness in 
the stomach after eating, variable appetite, and sooner or later nausea 
and vomiting. In cancer of the stomach, however, in addition to the 
pain in the region of the stomach, the patient complains of lancinating 
pains extending to the spine and frequently along the spine, and this is 
often, according to my observation, much more distressing than the pain 
experienced in the region of the stomach. 

In a case of cancer of the pyloric extremity of the stomach which had 
been progressing for many years, that came under my care the past 
season, the patient, a lady of about forty, was constantly annoyed by 
the most distressing pain along the spine, and though she had an indif- 
ferent appetite, with some acidity of the stomach, and at last vomiting 
of a darkish glairy fluid ; the prominent symptoms in the case were the 
pain along the spine, loss of appetite, and emaciation towards the fatal 
termination of the disease. 

Generally, however, there is vomiting early in the disease, of a glairy 
mucus ; later it becomes sour, and finally bloody, giving it the appear- 
ance of coffee-grounds or soot and water. This appearance of the matter 
vomited, the loss of appetite, the pain extending to and along the spine, 
together with the peculiar cathetic countenance, and the great emacia- 
tion which occurs, with perhaps a tumor in the region of the stomachy 
are the most prominent symptoms of this disease. 

Anatomical Characters. — The stomach may be found contracted or 
very much enlarged, especially if the pylorus is the seat of the disease ; I 
have seen the stomach dilated to more than twice its ordinary capacity, 
and adhering to the parietes of the abdomen. 

The cancerous disease may occupy any portion of the stomach, but it 
is more frequently found at the cardiac or pyloric orifice, and sometimes 
extends even beyond the stomach, along the duodenum or oesophagus. 

If ulceration has not taken place, the coats of the stomach are whitish, 
indurated, semi-cartilaginous, and more or less thickened. The thicken- 
ing may be very slight, but I have seen it an inch or more, so as nearly 
to close the pyloric orifice. The disease may be confined to the mucous 
membrane, but it may involve the submucous cellular tissue, and even 
the muscular and peritoneal coats, as has been the case in most exami- 
nations that I have made of this affection. 

Instead of mere thickening and induration of the coats of the stomach, 
there may be roundish masses projecting either from the mucous mem- 
brane into the stomach, or from the peritoneal coat into the cavity of the 
abdomen. And this tumor may be white and indurated, constituting 
scirrhus; soft or brain-like, constituting medullary cancer; or it may 



CANCER OF THE STOMACH. 353 

consist of cells filled with a gelatinous deposit, separated by fibrous 
partitions constituting colloid cancer. 

If the patient has died at a very advanced stage of the disease, ulcers 
are found in different stages of their progress ; the peritoneal coat in such 
cases having often contracted adhesions with the pancreas, spleen, liver, 
and in one case that I examined, with the abdominal parietes. The 
disease, in such cases, penetrates these parts in its destructive progress ; 
and in one case that I examined, the pancreas was completely destroyed, 
being converted into an ulcerated mass. 

Diagnosis. — Cancer of the stomach may generally be distinguished 
from chronic ulcerative gastritis, by the cachectic countenance, the tumor 
in the epigastrium, the pain along the spine, the steady, but perhaps 
slow progress of the disease, the obstinate and repeated vomitings, the 
steady and great emaciation, sometimes leaving little more than the 
skin and bones, and by the evidence of a hereditary tendency to the 
disease. 

Some of these symptoms, it is true, exist in chronic ulcerative gas- 
tritis, but generally not in as marked a degree, at least according to my 
observation, in these affections. In cases in which the disease extends 
to the pancreas, I have noticed that the appetite sometimes becomes 
entirely indifferent, the patient eating one thing as readily as another. 

Causes. — There is evidently a hereditary predisposition to cancerous 
affections in some constitutions, but in what that predisposition consists 
is not quite certain. It is probable, however, that the various impru- 
dences of parents are visited upon their children in this predisposition, 
as well as in all others which are inherited. 

The exciting causes are various irritants, such as excesses in eating, 
indigestible articles of food, alcoholic liquors, stimulant medicines, such 
as capsicum, &c, and besides, the disease is doubtless produced, in some 
cases, by depressing mental emotions, and perhaps by excessive venery, 
and various other kindred abuses of the system. 

Prognosis, — The prognosis in cancer of the stomach is always unfavor- 
able, but by a rigid observance of the laws of health, and palliative 
measures, some cases may live on perhaps for several years, with the 
certainty, however, of its producing a fatal result, unless the patient 
should be cut down by some other cause. Cancer of the stomach may 
however pass on rapidly to a fatal termination. 

Treatment. — The treatment of cancer of the stomach must be strictly 
palliative, and that which is of most importance is a proper regulation 
of the diet. The patient should be directed to take a plain digestible, 
and nourishing diet, with strict regularity. And among the articles 
most suited for such patients are bread and milk. The drinks should 
be water, or milk and water, in which, if there is acidity of the stomach, 
small quantities of lime-water may be taken, or of the bi-carbonate of 
potassa, or prepared chalk. If the symptoms of gastric irritation be 
aggravated from any cause, cups, leeches, or blisters may be applied to 
the epigastrium ; and in the very last stages of the disease, anodynes of 
conium or hyoscyamus may be required. 

23 



854 DISEASES OF THE DIGESTIVE SYSTEM. 

SECTION X.— PERITONEAL ENTERITIS. 

By peritoneal enteritis, I mean inflammation affecting mainly the 
peritoneal coat of the intestines, but extending more or less, in most 
cases, to the muscular coat. The peritoneum, it must be remembered, 
is a serous membrane, which, after lining the abdominal cavity, extends 
over the intestines, forming their external or serous coat. Now this 
outer or serous coat of the intestines is liable to be the chief seat of 
intestinal inflammation ; the muscular coat is generally, however, more 
or less involved. 

Symptoms. — Peritoneal enteritis usually commences with a feeling of 
uneasiness in some part of the abdomen, which after a longer or shorter 
period terminates in a fixed burning pain, generally in the umbilical 
region, and finally becomes gradually diffused throughout the whole 
abdomen, or most of it at least. If the inflammation is confined to the 
serous and muscular coats of the intestines, there is generally obstinate 
constipation. Nausea and vomiting generally attend, and sometimes 
even stercoraceous matter is thrown up. 

The tongue is generally dry, and may be covered with a white fur, 
having red edges, but in some cases there is a streak of brown fur along 
the middle. The thirst is usually urgent, the urine scanty, and high 
colored, and sometimes voided with considerable difficulty. The skin 
is hot and dry on the body, but it may be moist on the forehead and on 
the hands. The pulse is usually frequent and tense, and the respiration 
is more or less disturbed, each inspiration adding to the local abdominal 
suffering. The patient lies on the back with the knees drawn up, to 
avoid pain from the pressure of the abdominal muscles. 

Sometimes this disease commences with chills, followed rapidly with 
febrile excitement, and finally with a state of collapse. If collapse super- 
vene, the extremities become cold, the pulse weak and undulating, the 
countenance cadaverous, the abdomen tense, and finally a sort of passive 
vomiting occurs, the contents of the stomach being apparently forced 
up by the distended intestines. 

Peritoneal enteritis is usually rapid in its course, and may terminate 
in gangrene, in which case the pain subsides, the pulse sinks, the coun- 
tenance becomes pale, the extremities cold, the surface is covered with 
a clammy sweat, and with perhaps hiccough and convulsions the patient 
finally dies. The acute form of this disease seldom continues more 
than one week, without terminating in resolution or death. 

Peritoneal enteritis may, however, assume a chronic form, in which 
case all essential symptoms of acute cases are developed, with less inten- 
sity, and the disease may pass on for weeks, or even months ; the mus- 
cular coat of the intestines probably always suffering more or less in 
such cases. 

Diagnosis. — Peritoneal enteritis, if it be in the arch of the colon, 
may be mistaken for pleuritis, or hepatitis, but it may be distinguished 
by attention to the following essential differences. In pleurisy the pulse 
is full, hard, and active, while in enteritis it may be contracted, quick, 
and frequent. In pleurisy the respiration is carried on mainly by the 
abdominal muscles, while in enteritis the chest expands freely, and the 



PERITONEAL ENTERITIS. 355 

abdominal muscles are comparatively quiet. In pleurisy pain is felt by 
pressure in the intercostal spaces, while in enteritis, pain is produced by 
pressure on the abdomen. 

Peritoneal enteritis may be distinguished from simple peritonitis, by 
the constipation and vomiting which attend the intestinal inflammation, 
which symptom is not a necessary attendant in simple peritonitis. 

From spasmodic pain, enteritis may be distinguished by attention to 
the following differences. In enteritis the patient lies quiet on the back, 
moving as little as possible, while in colic he throws himself about con- 
tinually. In enteritis the pain is increased by pressure, while in colic 
it is often a relief. In enteritis the pain is continuous, while in colic it 
often intermits for a time. In enteritis the skin is hot and dry, and 
there is thirst, while in colic there is no thirst, and the skin is nearly 
natural or moist. 

Finally, in discriminating between peritoneal and mucous enteritis, 
we should remember that in peritoneal enteritis the bowels are consti- 
pated, while in mucous enteritis there is generally a diarrhoea. 

Anatomical Characters. — Resolution is the only favorable termination 
in peritoneal enteritis, and when it occurs, it may be attended with a 
moderate diarrhoea. There is generally found on post-mortem examina- 
tion of patients dead of this disease, a gangrenous appearance ; but it is 
possible that this disease sometimes terminates fatally in the early 
stages, by the shock to the general system. In some cases, if the inflam- 
mation has been considerable, coagulable lymph is thrown out and folds 
of the intestines have thus formed adhesions, presenting an irregular 
mass, more or less sero-purulent fluid being generally found in such 
cases in the cavity of the abdomen. 

Causes. — Various causes operate to produce peritoneal enteritis, 
among the most frequent of which are fecal accumulations in the bowels, 
mechanical injuries, hernia, drastic purgatives, sudden suppression of 
the perspiration from cold, metastasis of external inflammations, as ery- 
sipelas, rheumatism, &c. 

Prognosis. — In cases in which the vomiting is moderate, and the pulse 
not contracted and obscure, there may be a good prospect of recovery 
with proper treatment. But in cases in which there is frequent and 
obstinate vomiting with a contracted and obscure pulse, considerable 
danger may be reasonably apprehended of a fatal termination of the 
case. 

Treatment. — At the very commencement of peritoneal enteritis, the 
inflammation may sometimes be arrested by placing the feet in warm 
water, applying cups on each side of the spine opposite the abdominal 
pain, and cups or leeches to the abdomen. After the cupping or leech- 
ing, a warm mustard poultice should be applied over the abdomen, and 
kept on till it has produced a good degree of irritation. Twenty drops 
of laudanum, or fifteen drops of the fluid extract of hyoscyamus with 
half a grain of camphor and a little prepared chalk, may be given every 
four or six hours to quiet pain and allay vomiting. The spine may be 
rubbed morning and evening with a strong infusion of capsicum in vine- 
gar. Two or three blue pills may be given, and followed in five or six 
hours with a full dose of castor oil. With this mild course of treatment 






356 DISEASES OF THE DIGESTIVE SYSTEM. 

I am satisfied that many cases of this disease may be arrested if resorted 
to early. But if the case has been neglected or mal-treated, it may 
require more active measures. 

In such cases general bleeding, warm pediluvia, cupping on each side 
of the spine, and cupping or leeching the bowels, and finally sinapisms 
over the abdomen, and blisters if the case is obstinate may be required. 
After the bleeding and cupping, a full dose of calomel in half an ounce 
of castor oil may be administered, and its operation aided by an injection 
if necessary. Full doses of opium or hyoscyamus may be given every 
four or six hours, and this gradually diminished in quantity and fre- 
quency, as the inflammation and pain subside. A liberal blister followed 
by a warm hop poultice over the bowels will generally be of very essen- 
tial service in such cases. 

Should symptoms of gangrene occur, the case should not be at once 
abandoned as hopeless. Stimulants, properly administered, may pos- 
sibly arrest the alarming symptoms in such cases. Camphor, the sul- 
phate of quinine, wine-whey, carbonate of ammonia, or even brandy may 
be administered ; and if they do not avert the fatal tendency, the atten- 
dant may have the satisfaction of having done what he could. 

Mucilages and toast-water may be allowed during the course of the 
disease, if the stomach will retain them. During convalescence the 
patient should be directed to take nothing but the most digestible and 
unirritating diet, even for several weeks, lest there be a return of the 
disease. 

In chronic peritoneal enteritis, the warm foot-bath at evening, cups 
along the spine, with cups or leeches to the abdomen, and finally blisters, 
mild laxatives, or enemata, with a light, plain, digestible diet, taken 
with regularity, constitute the treatment proper in such cases. After an 
attack of enteritis, the bowels are peculiarly liable to distension by wind, 
to relieve which, and to give tone, a weak infusion of columbo, or from 
one fourth to half a drachm of the fluid extract may be given, three 
times per day, immediately after each meal, and continued for a time. 

SECTION XI.— MUCOUS ENTERITIS. 

By mucous enteritis, I mean here inflammation of the mucous mem- 
brane of the small intestines, including the duodenum, jejunum, and 
ileum ; and also of the large intestines, if not attended with griping 
pains in the lower portion of the abdomen, and mucous or bloody evacua- 
tions. But that variety of inflammation of the large intestines, involving 
mainly the colon and rectum, and attended with tenesmus and mucus 
or bloody evacuations, I shall consider in the following section. — The 
length of the intestines, it should be remembered, is about thirty feet, 
of which the small intestines constitute about twenty-five, and the large, 
the remaining five feet. The large intestines may become involved, to 
some extent, with the small intestines, in simple mucous enteritis, with- 
out developing the ordinary symptoms of dysentery, or griping pains, 
with mucous or bloody evacuations. While then, by simple mucous ente- 
ritis, I mean mainly inflammation of the mucous membrane of the small 
intestines; it must be remembered that I include under this head simple 






MUCOUS ENTERITIS. 357 

mucous inflammation of the large intestines, not attended with griping 
pains, and mucous or bloody evacuations. It should be remembered also 
that while the mucous membrane of the intestines, and especially of the 
small intestines, is the principal seat of this disease, the inflammation 
may extend to the muscular, and even to the serous coat of the intes- 
tines. — Let us now proceed to the consideration of inflammation of the 
mucous membrane of the intestines, commencing with those that are 
developed, if the duodenum be the seat of the inflammation. 

Symptoms, — If the duodenum be the seat of the inflammation, there 
may be pain in the vicinity of the pylorus, and more or less pain in the 
back, along the lower portion of the dorsal region. There is also many 
of the symptoms common to gastritis, together with a yellowness of the 
skin, and generally a yellow appearance of the urine. If the inflamma- 
tion be of a chronic character, food taken is apt to produce pain an hour 
or two after eating, and the same is true in acute cases if food be taken. 
Finally, if the duodenum alone be the seat of the inflammation there is 
generally little or no diarrhoea, and there may be constipation. 

If, however, the inflammation extends along the mucous membrane of 
the jejunum and ileum, and perhaps the large intestines, the following 
symptoms may be expected. In the acute form of mucous enteritis, there 
is at first uneasiness, followed by griping pains, which gradually in- 
crease, and very soon there is more or less tenderness on pressure. The 
pain may occupy any portion Of the abdomen, but the region of the 
umbilicus is its most frequent seat. 

Soon after mucous enteritis becomes established there is along with 
the griping pains, in most cases a diarrhoea, especially if the inflamma- 
tion extends to the lower portion of the small intestines. The diarrhoea 
may be continuous, or it may cease for a little time, and then suddenly 
return from very slight causes. The discharges are generally of a liquid 
character, being an increased serous exhalation, with or without bile, and 
perhaps some fecal matter. There may be tympanitis, and in some cases 
if the muscular and serous coats become involved, there may be consti- 
pation of the bowels instead of diarrhoea. 

More or less febrile symptoms are developed, either before or after the 
symptoms which are developed by the local inflammation, and the febrile 
symptoms may be either continued, remittent, or even almost intermit- 
tent, the paroxysms being preceded by slight chilliness in many cases. 
The pulse is excited, the skin quite dry, and the urine scanty, and head- 
ache is an occasional, though not an invariable attendant. The disease 
may terminate favorably in a few days, or the pain and tympanitis may 
increase, the tongue become red and dry, the pulse frequent, and the 
patient may recover after a lingering illness, or the inflammation may 
extend to the muscular and serous coats, or perhaps ulceration and per- 
foration occur, and the case terminate unfavorably. 

Such are the ordinary symptoms of acute mucous enteritis, but the 
disease may become chronic, or it may assume a chronic form from the 
first, in which case the same train of symptoms are developed, with less 
intensity, if we except perhaps the diarrhoea, which is often more con- 
siderable and obstinate than in acute cases. 

Chronic mucous enteritis is generally attended with serous evacuations, 



358 DISEASES OF THE DIGESTIVE SYSTEM. 

more or less frequent, which, however, in the latter stages may be min- 
gled with more or less pus. There is generally some pain, and more or 
less tenderness ; the pain being aggravated by a movement of the bowels, 
and sometimes at a period of a few hours after each meal. The appetite 
may be variable, or craving, the skin dry, the tongue furred, the pulse 
frequent ; there is more or less emaciation ; and, finally, the patient is 
irritable and gloomy, magnifying every unfavorable symptom, and ap- 
pearing blind to every indication of a favorable termination. Chronic 
mucous enteritis may terminate in a few days, or it may run on for 
weeks, months, or even years, with occasional remissions and exacerba- 
tions, till at last, irritable, worn down and emaciated, the patient is re- 
lieved by death from his protracted sufferings. 

Anatomical Characters. — In acute mucous entritis, the mucous mem- 
brane is found reddened, brown or of a livid appearance. And this red- 
ness may be uniform, or in patches. The follicles may be enlarged, and 
perhaps ulcerated on their points, and surrounded by more or less red- 
ness ; or several of these may run into each other, forming an irregular 
ulceration. 

Ulcers may also exist in any portion of the mucous membrane. Or 
they may extend to the submucous, and even through the muscular coat 
of the intestine, and sometimes the serous coat may be found ruptured, 
the whole peritoneum in such cases presenting signs of inflammation. 
In some cases portions of the bowels are found gangrenous, their con- 
tents having escaped into the peritoneal cavity. 

In cases of mucous enteritis that become chronic, or that are chronic 
from the first, in addition to the appearances presented in acute cases, 
the mucous membrane appears covered with prominent ulcerated follicl es, 
and the intervening ulcers are more numerous, generally, than in acute 
cases. And in very protracted chronic cases, in scrofulous patients, the 
mesenteric glands may be found enlarged, and either suppurating or 
indurated. 

Diagnosis. — Mucous enteritis may be distinguished from peritoneal 
enteritis by attention to the following differences. In peritoneal ente- 
ritis there is great tenderness and intense pain, of a sharp, lancinating 
character, as well as protracted vomiting and obstinate constipation ; 
while in mucous enteritis the pain is less acute, and the tenderness very 
much less, and little or no vomiting. 

In colic the pain is more severe, but may be relieved on pressure, and 
there is constipation of the bowels, with little or no fever, by which it 
may be distinguished from mucous enteritis. 

Causes. — Among the causes of mucous enteritis are atmospheric vicis- 
situdes, the translation of cutaneous eruptions, the suppression of accus- 
tomed discharges, and the retrocession of gout, rheumatism, &c. It may 
also be produced by crude articles of food, drastic medicines, and various 
irritating or poisonous substances swallowed. Besides, mucous enteritis 
may be produced by acrid bile, and other secretions, by intestinal worms, 
and it may be a result of scalds, burns, &c, or it may arise during the 
continuance of febrile and other affections. 

Treatment. — At the very commencement of acute mucous enteritis, if 
the disease be active, and the patient of a strong, vigorous constitution, 



DYSENTERY. 359 

blood may be taken from the arm, if necessary ; and if there be consti- 
pation, a cathartic of calomel and castor-oil may be administered. Im- 
mediately after the general bleeding, when it is necessary, and at first 
when it is not, cups should be applied along each side of the spine, and 
two or three ounces of blood taken, and cups or leeches applied to the 
abdomen. 

The warm foot-bath should be used morning and evening, warm fomen- 
tations of hops applied over the abdomen, and if there is pain, with 
diarrhoea, fifteen or twenty drops of laudanum may be given, with a 
little prepared chalk, every four or six hours, and this may be con- 
tinued till the disease is arrested. The patient should be nourished 
during the acute stage of the disease, by mucilages, or crust coffee, with 
a little milk, and as convalescence approaches, the return to the use of 
solid food should be cautious and gradual, and every possible care should 
be taken to prevent a relapse. 

Should the inflammation assume a chronic form, and in all chronic 
cases after the cupping along the spine, and cupping or leeching of the 
abdomen, blisters over the stomach and bowels, repeated if necessary, 
will be of very essential service and should not be neglected. If there 
be diarrhoea, Dover's powder or laudanum, with a little prepared chalk, 
and if necessary, tannin may be given every four or six hours and con- 
tinued till the diarrhoea is corrected. 

In very chronic cases, a pill of one grain each of the sulphate of iron, 
extract of gentian and extract of conium may be given after each meal, 
and if symptoms of ulceration occur, one-fourth of a grain of the nitrate 
of silver may be substituted in the pill for the sulphate of iron, and given 
after each meal, till an impression is produced upon the diseased mem- 
brane. 

In chronic mucous enteritis, a plain, digestible, and unirritating diet 
only should be allowed ; and among the articles most likely to be accept- 
able to the patient are arrow-root, rice, bread and milk, &c. The food 
should be taken with regularity, and every precaution should be taken 
that nothing be done to aggravate or perpetuate the disease. 

In those cases of mucous enteritis which occur in bilious and other 
fevers, and which are indicated by a dry tongue, tympanitis, and perhaps 
diarrhoea, a blister should be applied to the epigastrium, and, if neces- 
sary, over the bowels, in addition to the other treatment which may be 
indicated in the case. By thus allowing only proper varieties of food, 
and fulfilling, as they arise, every indication, and doing nothing more, 
most cases of acute or chronic mucous enteritis may be palliated, and 
generally permanently cured. 

SECTION XII.— DYSENTERY— {Bloody Flux.) 

' By dysentery, I mean that variety of inflammation of the mucous 
membrane of the large intestines, and extending sometimes along the 
small intestines, attended with griping pains in the lower portion of the 
abdomen, mucous or bloody evacuations and tenesmus. Inflammation of 
the mucous membrane of the large intestines including the caecum, colon, 
and rectum, may exist from various causes, in connection with that of the 



360 DISEASES OF THE DIGESTIVE SYSTEM. 

small intestines, or even independent of it, and not be attended with 
tenesmus and mucous or bloody discharges ; in which case the disease 
falls under the head of mucous enteritis, which I have considered in the 
preceding section. 

Let us now proceed to the consideration of that variety of inflamma- 
tion of the mucous membrane of the intestines, and especially of the 
large intestines, attended with pain in the lower portion of the abdomen, 
mucous or bloody evacuations and tenesmus, constituting dysentery or 
bloody flux. Dysentery may be either benign or malignant, and it may 
assume an acute or chronic form. I shall treat here only of the simple 
or benign variety, leaving the consideration of malignant dysentery for 
the following section. 

Symptoms. — Simple dysentery generally commences with slight chills, 
a loss of appetite, a bad taste in the mouth, and a slightly depressed 
pulse ; soon the chills alternate with flushes of heat ; there is thirst ; a 
dry skin ; pains in the lower portion of the abdomen, and either consti- 
pation or diarrhoea. Or the disease may come on suddenly, with chilli- 
ness, griping pains, and mucous bloody stools, without any marked pre- 
monitory symptoms, and especially is this the case when it arises from 
sudden exposure to cold, or from irritants acting directly upon the intes- 
tinal mucous membrane. 

In some cases febrile symptoms are developed before the dysenteric dis- 
charges appear, while in others the bloody mucous stools are, as we have 
seen, among the first symptoms which are developed. During the whole 
course of this disease, there are generally no fecal discharges, the stools 
consisting entirely of intestinal mucus, mixed with more or less blood. 
Tenesmus too is one of the most constant symptoms in this disease, and 
its degree of severity generally indicates more or less the degree and 
extent of the intestinal inflammation. In some cases the discharges are 
almost entirely of intestinal mucus, but generally it is mingled with more 
or less blood. 

In some cases there is only a slight fever, while in others there is a 
high state of febrile excitement. And in the latter stages of unsubdued 
cases, a colliquative diarrhoea may occur and various other unfavorable 
symptoms may supervene. The pulse becomes small, corded and very 
frequent, the countenance contracted, the abdomen tender, the skin 
harsh, and considerable prostration may attend the disease. The skin is 
generally harsh and dry through the whole course of the disease, the 
urine is scanty and high colored, and the hepatic functions are often 
more or less deranged. 

Cases of simple dysentery generally terminate favorably in seven or 
eight days with proper treatment. But if cases be neglected or mal- 
treated, they may pass on to a chronic form and continue perhaps for 
weeks, months, or even years ; the inflammation in such cases involving 
to a greater or less extent, the mucous membrane of the small intestines. 

Chronic dysentery is characterized by frequent small evacuations, con- 
sisting mostly of mucus mingled sometimes with blood, and more or less 
purulent matter with bilious or feculent discharges. The symptoms are, 
however, in the main similar to those of the acute form, being developed 
with less intensity ; and if the disease be mainly confined to the lower 






DYSENTERY. 361 

portion of the intestines, the constitutional symptoms may be slight, even 
though the disease continue for a long time. But very protracted cases, 
especially if the patient be of a scrofulous constitution, are apt to be 
attended with emaciation, a sallow and shrunken countenance, general 
debility, and unless arrested, finally lead on to dropsy, consumption, or 
some other fatal affection. 

Dysentery, whether acute or chronic, is liable to various modifications, 
depending upon the condition of the patient, at the time of attack, and 
also upon the accidental circumstances of locality, comfort or want, &c. 
All these circumstances should be taken into account in the examination 
and treatment of patients suffering from dysentery as well as in all other 
affections. 

Diagnosis. — The presence of pain in the lower portion of the abdomen, 
of tenesmus, and of mucous or bloody evacuations, together with the 
other symptoms which I have enumerated, are sufficient to characterize 
a case of dysentery. But to distinguish the benign from the malignant 
variety of the disease, it becomes necessary to take into account the 
extrinsic circumstances, such as the condition of the patient, the epi- 
demic or endemic influence, &c. 

Causes. — Various causes operate to produce this disease, but cold 
damp air, after the body has been heated, by a hot summer or autumnal 
sun, is by far the most frequent cause, in temperate climates. During 
the months of August and September, the days in our latitude are 
usually warm, and the exhalation from the skin free ; but as night 
approaches, the cool damp air irritates the extreme nerves of the skin, 
the exhalent tubes are closed, the small capillaries contracted, and an 
internal congestion produced. This internal congestion injects the 
minute capillaries of the mucous membrane of the alimentary canal, and 
produces irritation. It is possible also that the blood, containing the 
retained perspirable matter, acts as a direct irritant to the mucous mem- 
brane, and also the sanguiferous and nervous system, exciting the circu- 
lation, and deranging the functions of the various organs. But the 
alimentary mucous membrane is the part in which the local congestion 
and inflammation appears most prominent, and hence the pouring out 
of a bloody mucus, attended with tenesmus, mainly from the large 
intestines. 

It is probable that the liver too, being in a congested state, obstructs 
the free passage of the blood through the portal vessels, and thus very 
essentially increases the congestion and inflammation of the alimentary 
mucous membrane. Now the cause being general, it is reasonable to 
suppose that the mucous membrane of the whole alimentary canal should 
suffer ; but in dysentery, or those cases in which there is tenesmus, with 
mucous or bloody discharge, the disease appears to develop itself, as we 
have seen, most prominently in the colon and rectum. In this way, it 
is, I believe, that cold, with dampness, produce in our climate the simple 
cases of dysentery, so common in August and September. 

It is possible, also, that the paludal poison, when it exists in the air, 
serves to predispose the system to this variety of disease ; as more cases 
occur in miasmatic districts than where this agent does not exist. It is 
probable, too, that crude and indigestible articles of food, and especially 



362 DISEASES OP THE DIGESTIVE SYSTEM. 

unripe fruit, coming as it does at the season when the days are warm, 
and the nights cool and damp, tend strongly to produce this disease, in 
those who are any way predisposed. 

Chronic dysentery is generally the result of the acute form of the 
disease ; hut it may arise from an extension of the inflammation, in 
hemorrhoidal, and other general or local affections, operating directly 
or through the general system. 

Anatomical Characters. — The whole alimentary mucous membrane 
may be found, on dissection, to present a more or less congested, and 
perhaps inflamed appearance, which however becomes more marked, as 
the large intestines are approached; while in the colon, and perhaps 
rectum, more or less ulceration is generally found. 

In that portion of the large intestines nearest the ileum the ulceration 
is apt to be superficial ; but if the examination be continued along the 
colon and rectum, the ulcerations are apt to be more extensive, and 
deeper, if we except the extreme portion of the rectum, in which there 
are frequently no ulcerations to be found. 

In cases of dysentery in which death has taken place early, the alimen- 
tary mucous membrane is found of a deep red color; and either soft and 
pulpy, or of a granular appearance. The liver is almost always 
functionally deranged in this complaint ; but in mild sporadic cases, or- 
ganic derangement very seldom occurs. In chronic cases, however, 
occurring in patients of scrofulous constitutions, abscesses and other 
organic changes of the liver may be found, together with extensive ulcera- 
tions of the alimentary mucous membrane, and especially of the large 
intestines. 

Prognosis. — The prognosis in simple uncomplicated cases of dysentery 
is favorable, if proper treatment be had. If, however, from some acci- 
dental complication, from neglect, or from mal-treatment, colliquative 
discharges occur, with tympanitis, cold extremities, a clammy sweat, and 
a frequent feeble pulse, with delirium, a fatal termination may be ex- 
pected. 

Treatment. — The indications to be fulfilled in the treatment of dysen- 
tery, are to equalize the circulation, to allay the irritation, and subdue 
the inflammation of the alimentary mucous membrane, and to restore a 
healthy action of the skin and liver. Hence, in the common simple 
dysentery, produced by atmospheric vicissitudes, and other causes, if the 
patient be seen early, the disease may generally be arrested by very mild 
measures, unless some complication arise. 

The feet should be placed in warm water, in order to call the blood to 
the extremities, and promote perspiration, which this simple measure will 
very frequently do. liubbing the back with a warm infusion of capsicum 
in vinegar, will also aid very materially, in equalizing the circulation, and 
restoring the action of the skin, if resorted to early, while chilliness 
prevails. 

A large mustard poultice should be laid over the stomach and bowels, 
covering the whole abdomen ; and reaching back towards the spine, and 
it should be allowed to produce a thorough irritation ; and this should be 
repeated, every six or eight hours, till the disease is arrested. If there 
has been a bitter taste in the mouth, and a poor appetite, for a few days, 



MALIGNANT DYSENTERY. 363 

and the digestion is bad, a cathartic of calomel, or hydg. cum creta, 
with rhubarb and castor oil may be administered, and a free motion of 
the bowels produced. 

After the operation of the cathartic, when it is indicated ; and at first, 
when it is not indicated ; five grains of Dover's powder should be given, 
every four or six hours, and the patient should drink freely of warm sage 
tea, to promote perspiration. Or, if little or no fever attend, fifteen or 
twenty drops of laudanum may be given instead of the Dover's powder. 
If this does not arrest the disease, the dose of the laudanum, or Dover's 
powder may be increased, and two grains of tannin given, either with, or 
alternating with the anodyne ; and this should be continued till the dis- 
ease is arrested. 

In cases not attended with much previous gastric derangement, a 
cathartic should not be given ; but a grain of calomel may be given with 
the Dover's powder or anodyne, till three or four grains have been given. 
This, however, may generally be omitted, and should not be resorted to, 
unless clearly indicated. 

In obstinate cases, which pass on to a chronic state, or in cases which 
through neglect or mal-treatment become chronic, a blister should be 
applied over the stomach, and if necessary to the abdomen, and if obsti- 
nate, cups or leeches may be resorted to in case blisters prove insufficient. 

In chronic cases which are obstinate, ten drops of the oil of turpentine, 
or ten drops of the balsam of copaiva may be given, in emulsion with 
sugar, gum arabic and water, three or four times a day, and continued 
for a long time. If, however, these measures fail, small doses of the 
nitrate of silver may be given instead, and continued for a reasonable 
time. 

Injections of fifteen drops of laudanum, in a fluid ounce of liquid 
starch, may be of very essential service in obstinate acute cases, while in 
chronic cases they may be of great service, used morning and evening, 
with a few grains of tannin or the sulphate of zinc. 

Toast water, with a little milk, may be allowed in acute cases, as well 
as arrow-root cooked in milk, or equal parts of milk and water, till the 
disease is arrested, and then a plain digestible diet should be directed 
for several days, and the patient should be warmly clad, and should 
avoid exposure to cool damp air for a long time. In chronic cases of 
this affection, a plain, digestible, and nourishing diet should be allowed, 
and the patient should wear flannel next the skin, and if possible, sleep 
in flannel sheets at night. 

SECTION XIII.— MALIGNANT DYSENTERY. 

By malignant dysentery, I mean that peculiar miasmatic affection in 
which the mucous membrane of the alimentary canal, and especially of 
the large intestines become the principal seat of the local inflammation, 
the disease being attended with serous or mucous and bloody discharges, 
pain, tenesmus, &c. 

It differs from simple dysentery, in being brought about by a mias- 
matic agent, acting through the brain and nervous system, developing a 
mucous inflammatory affection, of a malignant character, affecting mainly 



364 DISEASES OF THE DIGESTIVE SYSTEM. 

the large, but more or less the small intestines, and being attended with 
great prostration and a typhous tendency. 

Symptoms. — There is generally a forming stage, during which the mias- 
matic agent is producing its effects upon the brain and nervous system, 
the various functions of the body becoming more or less deranged. There 
is a bitter taste in the mouth, loss of appetite, headache, restlessness 
during the night, and general irritability of the nervous system. Soon 
there is chilliness, attended with headache, thirst, difficult breathing, 
violent pains in the head, back and limbs, and severe pain in the 
abdomen. 

After the chills, reaction is set up, generally with increased pain in 
the bowels, and dysenteric discharges, with violent tenesmus, attended 
with a sense of weakness and general prostration of the powers of the 
system. The discharges may be, at first, of a bloody mucous character, 
but frequently become in a little time of a reddish watery, and finally of 
a dark putrid appearance, looking very much like dissolved blood, and 
the discharges are attended with severe tenesmus, and marked fainting, 
sinking symptoms. 

The general fever which is developed may be of an active grade, but 
it generally inclines to a typhoid character, very soon after the bloody 
serous discharges commence. And unless the disease be arrested, the 
discharges increase in frequency, the extremities become cold, the 
breathing oppressed, the abdomen exceedingly tender, the thirst urgent, 
the tongue dark and dry, the pulse small, tense and thread-like, and be- 
fore the fatal termination, there may be a dark, putrid, or bloody serous 
fluid thrown from the stomach, very similar to that passed from the 
bowels. 

Such are the ordinary symptoms of malignant dysentery, but in some 
cases the patient sinks rapidly from the very -first, the discharges being 
putrid, the countenance cadaverous, livid spots appearing, and finally, 
delirium, stupor, and death being the result. 

Anatomical Characters. — The post-mortem in cases of malignant 
dysentery reveals signs of inflammation of the alimentary mucous mem- 
brane, involving sometimes the stomach and small intestines,but more 
especially the large intestines. The mucous membrane presents a dark 
livid appearance, or it may be mortified, or it may present more or less 
extensive patches of ulceration, in the large intestines, and perhaps along 
the small intestines, even to the stomach. The mesenteric glands are 
sometimes found enlarged and softened, and abscesses or some other 
organic change of the liver may be found in some cases. 

Diagnosis. — There is generally no difficulty in distinguishing malig- 
nant dysentery, after the first few cases, as it generally prevails epidemi- 
cally, or in some special locality in which filth, bad air, and other 
unfavorable circumstances serve to render it so. It may be distinguished 
from simple dysentery by the marked premonitory symptoms of debility, 
prostration, and irritability of the nervous system, and the general 
derangement of the stomach, liver, and other organs of the body, and 
also by the watery, bloody, or putrid appearance of the discharges, as 
well as the rapidly fatal tendency of the disease. 

Causes. — Koino and idio-miasmata are together the cause of malignant 



MALIGNANT DYSENTERY. 365 

dysentery, or either of the causes may operate separately, to produce 
the disease. The febrific agent or agents, appear to act upon the brain 
and nervous system to produce prostration, and also probably directly 
upon the mucous membrane of the alimentary canal, and in something 
the same manner that it does in yellow, and other putrid fevers, and 
when idio-miasmata is the agent or one of the agents, I suspect that the 
blood becomes more or less dissolved, as in putrid fevers. It is probable 
also that prevailing, as it is apt to, at a season of the year when the 
days are warm and the nights cool, that atmospheric vicissitudes has an 
agency in producing malignant, as well as simple dysentery. 

Pathology. — As we have seen, the general cause or causes, operate to 
prostrate the powers of the brain and nervous system, the blood becomes 
more or less dissolved, the various functions of the system deranged, the 
liver congested, and the portal circulation obstructed, and as a result, 
the pain, tenesmus, putrid discharges, and typhous symptoms are de- 
veloped, which are followed, if the disease be not arrested, by a cadaver- 
ous countenance, delirium, and death. 

Prognosis. — The prognosis in malignant dysentery is generally un- 
favorable, but if attended to properly at once, some cases may terminate 
favorably. The favorable symptoms are a subsidence of the pain, tenes- 
mus, putrid discharges, &c, while the unfavorable are an aggravation of 
all the symptoms, with a cadaverous countenance, cold extremities, and 
delirium, together with a rapid sinking tendency. 

Treatment. — Owing to the great prostration of the general powers of 
the system, cathartics, or anything of that character, are entirely inad- 
missible in malignant dysentery. This may be too, in part, owing to the 
excessively irritable and inflamed condition of the alimentary mucous mem- 
brane, for the mucous membrane of the stomach and small intestines are 
often involved, as well as that of the colon and rectum, though gene- 
rally in a less degree. 

If the patient be seen at the very commencement of the disease, 
twenty drops of laudanum, with a teaspoonful of brandy, mixed with as 
much loaf sugar, may be administered, at once, and repeated every three 
or four hours ; sinapisms being thoroughly applied over the whole abdo- 
men. If this treatment be resorted to early, the disease may possibly 
be arrested at once, but if the case be neglected, or if it be improperly 
treated at first, the disease may continue from ten to fourteen days, un- 
less the case sooner terminates fatally. 

In cases which are not thus early arrested, and the chilly stage is fol- 
lowed by febrile reaction, four grains of Dover's powder, with two grains 
of the sulphate of quinine, may be given every six hours, and continued 
till typhoid symptoms supervene, when two grains each of camphor and 
tannin may be given, in addition to, and alternating with the quinine 
and Dover's powder, every six hours. This course of treatment may be 
continued throughout the disease, being modified of course to fulfill the 
indications as they arise. 

If the tenesmus be very distressing, and the discharges frequent, in- 
jections often drops of laudanum, with an ounce of fluid starch, may be 
of very essential service, used three or four times per day. As much 
irritation should be kept up over the stomach and bowels, with mustard, 



366 DISEASES OP THE DIGESTIVE SYSTEM. 

as can be borne, without producing vesication ; and in cases that are ob- 
stinate, and attended with tenderness, tympanitis, &c, even blisters may 
sometimes be indicated. Warm toast water, with milk, may be allowed 
at first, and later arrow-root cooked in milk and water, or mutton or 
chicken broth, may be allowed, till the patient is restored. 

SECTION XIV.— CANCER OF THE INTESTINES. 

By cancer of the intestines, I mean that variety of malignant disease 
of the intestines, attended usually with a livid scirrhous tumor, which 
ulcerates, or may ulcerate. Every part of the intestines are liable to a 
cancerous affection, but the duodenum, caecum, sigmoid flexure of the 
colon and rectum are the parts in which this affection most frequently 
occurs. 

Symptoms. — The early symptoms of cancer of the intestines are more 
or less pain or uneasiness in the part affected, and also pain in that por- 
tion of the spine opposite the intestinal disease. As the calibre of the 
intestine becomes materially diminished, there is apt to be constipation, 
and if the deodenum be the seat of the disease, more or less frequent 
vomiting is liable to occur. 

Sharp lancinating pains are liable to occur, and to be referred to some 
part of the abdomen, and to extend to, and more or less along the spine. 
Especially are these pains liable to occur at a particular period after 
eating. If the duodenum be the seat of the disease, the pain generally 
occurs, attended perhaps with vomiting, about three hours after eating ; 
but if the disease be seated lower along the intestines, the period becomes 
a little longer, till we reach the rectum, at which point the pain may be 
acute, only at or near a movement of the bowels. 

When ulceration occurs, there may be a diarrhoea, with bloody or 
sanious evacuations, which increase, and finally become very offensive ; 
and if the disease be situated in the colon or rectum, there is apt to be 
the most distressing tenesmus. After ulceration commences, emaciation 
progresses rapidly, the countenance is cachetic, the appetite fails, the 
pains become distressing, and, finally, the patient exhausted of flesh, 
strength and courage, dies, after a train of the most distressing suf- 
ferings. 

Anatomical Characters. — The appearances presented on post-mortem 
examination are similar to those of the disease when it affects the 
stomach. The parietes of the bowels are apt to be thickened, rendering 
the calibre very small, or there may be tumors projecting into their 
cavity, and perhaps ulceration, of greater or less extent, may be found. 
Not unfrequently the disease is found to have extended to the kidneys, 
liver, or pancreas. In one case I found the pancreas a complete ulcer- 
ated mass. 

Diagnosis. — If the disease be of the rectum, it may be detected by 
passing the finger, which will encounter a hard resisting mass, per- 
haps nearly closing the passage. If it be of the duodenum, it may be 
detected by the pain, of a lancinating character, which occurs about 
three hours after eating, together with the vomiting. And if the disease 
be situated at any intervening point, along the intestines, it may gene- 



ACUTE PERITONITIS. 367 

rally be distinguished by the countenance, the pain, and the constipa- 
tion, together with all the other symptoms which are developed. 

Treatment. — During the early stage of the disease, cups, leeches, or 
blisters may be applied over the seat of the disease, and cups along the 
spine opposite. Later, conium, hyoscyamus, or stramonium, may be 
indicated, to allay pain and produce relaxation of the intestine, either 
taken internally, or used by injection, if the disease be of the rectum. 
The diet should be mush or corn-bread, and milk. 

SECTION XV.— ACUTE PEKITONITIS. 

By acute peritonitis, I mean acute inflammation of the peritoneum, but 
especially of that portion lining the abdomen, and reflected over the 
abdominal and pelvic viscera, except that which belongs exclusively to 
the serous coat of the intestines, which I have considered in a previous 
section, under the head of peritoneal enteritis. It must be remembered, 
however, that in general acute peritonitis, that portion of the membrane 
reflected over the intestines is very liable to become involved. 

It must be borne in mind, that the peritoneum is a serous membrane, 
which lines the cavity of the abdomen, and is then reflected over the 
abdominal viscera, and also descends into the pelvis in front of the 
rectum, from whence it extends over the posterior surface of the blad- 
der, and also of the vagina and uterus in the female. 

The peritoneum thus constituted, with its various folds and reflections, 
is liable to become inflamed, the symptoms of which we will now proceed 
to consider. 

Symptoms. — Acute peritonitis is generally preceded by a feeling of 
lassitude, pain in the back and limbs, and slight creeping chills, alter- 
nating with flushes of heat. There may also be headache, and a feeling 
of uneasiness in the epigastrium, during the first stage of the disease. 
Immediately succeeding the chills, or else after febrile reaction is estab- 
lished, pain commences, perhaps in a small space at first, but it soon 
extends throughout the whole abdominal cavity. In some cases, how- 
ever, the pain is not general but local, and either stationary or wander- 
ing ; and in some rare cases, only a slight uneasiness is felt in the 
abdomen. 

While pain is thus a general attendant on acute peritonitis, tenderness 
is, I believe, an invariable symptom if firm pressure be made on different 
parts of the abdomen. The patient lies on his back with the knees drawn 
up and the shoulders elevated, in order to take off the tension of the abdo- 
minal muscles, and also the pressure of the bed clothes. 

The bowels may become constipated, especially if that portion of the 
peritoneum forming the outer coat of the intestines becomes involved in 
the inflammation. The pulse is generally frequent, tense, contracted and 
sharp, but sometimes it is round and full. The tongue may be moist and 
covered with a white fur, the edges sometimes becoming red in the pro- 
gress of the disease. 

In some instances the stomach sympathizes strongly with the abdomi- 
nal affection, and frequent nausea and vomiting may occur, especially if 
the intestinal peritoneum becomes involved. The face is generally pale 



368 DISEASES OF THE DIGESTIVE SYSTEM. 

and exhibits an expression of anxiety, the patient is wakeful, and de- 
lirium is apt to occur towards the termination of fatal cases. The abdo- 
men may remain flat or contracted, but it generally becomes tense and 
elastic during the course of the disease. 

The respiration is oppressed, each inspiration producing an aggrava- 
tion of the pain. In consequence of this, the respiration is carried on 
mainly by the expansion of the chest with little or no aid from the abdo- 
minal muscles. The secretion of urine is generally more or less sup- 
pressed ; and when that part of the peritoneum covering a portion of the 
bladder becomes involved, it is voided with difficulty, and a good deal of 
pain is experienced in that region. When that portion of the peritoneum 
adhering to and covering the inferior surface of the diaphragm, becomes 
involved in the inflammation, hiccough is a very constant attendant. 
When peritonitis occurs in the puerperal state, the lochia generally cease 
to flow, the secretion of milk is diminished, and the general powers of 
the system sink much earlier than when it occurs in other conditions of 
the system. 

Acute peritonitis may be connected with a typhoid condition of the 
system, the inflammation being of a passive character, the pulse being 
feeble, the tongue dark and dry, and finally along with great debility 
there may be a hemorrhagic tendency, with delirium, coma, &c. 

Acute peritoneal inflammation is generally rapid in its course, seldom 
continuing more than a week without terminating in resolution or death, 
or else passing into a chronic state. Violent eases may terminate fatally 
in two or three days, or even earlier than that. If, however, the inflam- 
mation assumes a subacute grade, the patient may continue on for several 
weeks. 

This variety of inflammation is liable to terminate in gangrene, and 
when it does, the extremities become cold and clammy, the countenance 
pale and contracted, and finally, slight wandering delirium occurs before 
a fatal termination. 

Diagnosis. — There is little difficulty in distinguishing acute peritonitis 
if proper attention be paid to its peculiar symptoms. The supine posi- 
tion, the pale countenance, the tenderness on pressure, and the con- 
tinuous pain, together with the drawing up of the limbs are sufficient to 
distinguish this disease from colic, spasmodic and neuralgic affections. 

From peritoneal enteritis, general inflammation of the peritoneum may 
be distinguished by the absence of constipation, which attends that dis- 
ease. But if the peritoneal coat of the intestines become involved in 
general acute peritonitis, constipation may attend. 

Anatomical Characters. — The post mortem appearances vary with the 
time at which death takes place. If the patient dies early, there may 
be only a redness of the peritoneum. If the case continue longer, before 
terminating fatally, there is apt to be a fibrinous exudation on the sur- 
face of the peritoneum, of a white or greenish-yellow color, perhaps 
organized, forming a false membrane, connecting more or less opposite 
or adjoining folds of the peritoneum. 

There is generally more or less liquid found in the cavity of the abdo- 
men, of either a colorless, whey-like, milky, sero-purulent, or bloody 
character, mixed sometimes with pus, or blood, and containing floating 






ACUTE PERITONITIS. 369 

fibrinous flake. Dark spots may be found, either the result of gangrene, 
or else of effused blood, occupying the submucous cellular tissue. 

In cases in which the peritonitis is the result of perforation of the in- 
testines, an offensive gas escapes on laying open the abdomen, and I 
have found the cavity containing a dark fetid liquid, with more or less 
fecal matter, the peritoneum presenting a dark injected appearance in 
most cases at least. In puerperal cases, the liquid found in the abdo- 
minal cavity is of a serous, milky, or bloody character. 

Causes. — Acute peritonitis may be the result of mechanical injury, 
violent exertion, stricture of the colon, hernia, the extravasation of 
blood, urine, or bile into the peritoneal cavity, the action of cold on the 
surface of the body, causing suppression of the perspiration, cold and 
wet feet, taking cold water when the body is in a free perspiration, the 
suppression of hemorrhoidal discharges, or of the menses, and metastasis 
of erysipelas, rheumatism, and other external inflammations. Acute 
peritonitis may also occur from an extension of inflammation of the 
womb, bladder, liver, stomach or intestines, or the disease may prevail epi- 
demically, in which case it is apt to assume a malignant typhoid character. 

Treatment. — If the patient be seen very early, there is a possibility of 
arresting the disease at once. The feet should be placed in warm water, 
and if there is chilliness, the back may be rubbed with an infusion of 
capsicum in vinegar. A large sinapism should be applied over the whole 
abdomen, and allowed to irritate a little short of vesication. By thus 
equalizing the circulation, promoting perspiration, and producing thorough 
counter-irritation, the internal congestion, irritation, and inflammation 
may often be arrested, and convalescence established. 

But we are not always so fortunate as to see patients thus early, and 
if we do, we may not always succeed so readily. If, then, this course of 
treatment fail, and in all cases in which acute peritonitis is fully esta- 
blished, other and more active measures may become necessary. In 
cases of acute peritonitis, of an active character, in strong and vigorous 
constitutions, general bleeding may be indicated, and when it is, should 
not be neglected. 

Immediately after general bleeding, when it is indicated, and at first, 
when it is not, cups should be applied along each side of the spine, and 
cups or leeches to the abdomen, and from four to six ounces of blood 
taken. 

After the cupping or leeching, sinapisms should be applied over the 
abdomen, and a cathartic of calomel and castor oil administered; and if 
the pain be severe, a full dose of opium may be given with the cathartic. 
About two grains of calomel, with five grains of Dover's powder may be 
given every four hours, and with every other powder half an ounce of 
castor oil may be administered, till a free movement of the bowels is pro- 
duced. A large blister should be applied to the abdomen, and then it 
should be kept covered with a warm hop poultice, moistened with vinegar, 
being laid over the blister at first, and then over the dressings, after 
vesication is produced. 

After getting the effects of the sinapisms, cupping, blistering, and 
cathartic; if the disease has in a good degree subsided, the calomel may 
be omitted, and five grain doses of Dover's powder continued every six 
24 



370 DISEASES OE THE DIGESTIVE SYSTEM. 

hours. If, however, the disease continues, the calomel should be con- 
tinued with the Dover's powder, and the blistering kept up over the ab- 
domen, till the inflammation is subdued. 

In cases of this character, which pass on to a state of collapse ; and in 
all cases of acute peritonitis of a passive character, attended with a ty- 
phoid condition of the system ; two grains each of the sulphate of quinine, 
and camphor, with five grains of Dover's powder, with or without two 
grains of calomel, may be given, and continued with dry cupping, blister- 
ing, &c, till the inflammation is subdued. And in case there be very 
great prostration, wine-whey, brandy, &c. may be given in addition, and 
continued till reaction is fully established. 

The nourishment in acute peritonitis should consist of toast water, with 
a little milk, rice-water, mucilages, &c; to which may be added, in case 
of collapse, or in typhoid cases, mutton, or chicken broth, arrow-root, a 
poached egg, &c, and wine-whey if necessary. During convalescence 
from this disease, the greatest care should be taken to avoid a sudden ex- 
posure to cold, lest by a sudden check of the cutaneous exhalation, a 
relapse be produced. 

SECTION XVI.— CHRONIC PERITONITIS. 

By chronic peritonitis, I mean a slow inflammation of the peritoneum; 
whether of a simple, or tuberculous character. Chronic inflammation of 
the peritoneum is quite a common occurrence ; but unless it be the result 
of the acute disease, it may come on in so insidious a manner, as not to 
attract special attention, until incurable structural changes have taken 
place, or there is effusion into the cavity of the abdomen. The disease 
may be simple or tuberculous, each variety having some symptoms in 
common, as well as others, which are peculiar to each. 

Symptoms. — In simple chronic peritonitis, there is slight pain in the 
abdomen, with more or less tenderness, experienced on pressure, as well 
as in coughing, sneezing, or from any sudden jar of the body; referred 
generally to the umbilical region. The abdominal pain, however, is not 
severe, and the inflammation may pass on to disorganization of the peri- 
toneum, without having been attended with any considerable pain. 

The abdomen may become tympanitic, and the patient may complain 
of tightness across the lower part of the abdomen, after exercise ; and 
indurated spots, which are more or less tender, may sometimes be found, 
consisting probably of folds of the intestines, which have contracted ad- 
hesions. The bowels are apt to be torpid in this disease, especially if 
the peritoneal coat of the intestines becomes involved in the inflammation. 
The pulse may remain nearly natural; or it may become accelerated, 
quick and contracted towards evening, in the early stages ; and almost 
continually so, in advanced periods of the disease. 

The appetite may be quite good, but in some cases occasional vomiting 
occurs ; the face is generally pale, with an expression of the countenance 
indicative of languor and ill health. There is apt to be a slight febrile 
exacerbation towards evening, with oppressed breathing and sometimes 
slight cough when the patient lies on the back. The feet, too, are apt to 
become edematous, and the urine scanty, about the time that effusion 
takes place into the abdomen. 






CHRONIC PERITONITIS. 371 

This disease may terminate in fatal disorganization in a few months, 
but cases occur in which it continues in a slow and insidious manner, for 
many months before the patient is worn down by the irritation it produces. 
Whether this disease be protracted or short in its duration, the inflamma- 
tion generally terminates in effusion into the cavity of the abdomen, this 
being frequently the manner in which ascitis is produced. 

In cases of chronic peritonitis depending upon tubercles in the perito- 
neum, the symptoms are very similar to those developed in simple peri- 
tonitis ; but the disease is apt to be steady in its progress and obstinate, 
being but slightly, if at all, affected by remedial measures. In this 
form of the disease, the external lymphatic glands are apt to be enlarged, 
and also the mesenteric glands presenting small tumors on a close exami- 
nation of the abdomen. Tuberculous peritonitis occurs in patients of a 
scrofulous diathesis, and is apt to be complicated with tubercles in the 
lungs, and in various parts of the system, and especially with tuberculous 
ulceration of the bowels and an obstinate diarrhoea. 

Anatomical Characters. — More or less fluid is generally found in the 
cavity of the abdomen, usually of a lightish whey-like color, but some- 
times of a yellowish or reddish appearance, containing more or less pus 
or blood. 

Different portions of the peritoneum are often found adhering, as well 
as folds of the intestines, by false membrane; or the intestines may be 
found adhering to the parieties of the abdomen. The false membrane 
may be thick and of a gray or dark red color, or it may be in small 
spots, appearing more or less thickly over the surface of the peritoneum. 

In tuberculous cases, in addition to the false membrane, the tuber- 
culous deposition may be found in distinct granulations or in agglomerated 
masses, and in various degrees of development. The mesenteric glands 
are apt to be found enlarged and more or less indurated, as well as the 
external lymphatic glands in various parts of the body. 

Causes. — Chronic peritonitis is frequently the result of the acute form 
of the disease, but it may occur from an extension of the inflammation in 
mucous enteritis, from congestion of the liver, interrupting the portal 
circulation, or from blows inflicted on the abdomen ; or it may occur from 
suppression of the perspiration, or from metastatis of erysipelas and other 
external inflammatory affections. Tuberculous cases arise from a here- 
ditary predisposition as well as various abuses of the system, such as im- 
pair digestion, and tend to produce a general scrofulous or tuberculous 
condition of the system. 

Treatment. — After ascertaining and removing the cause, as far as may 
be, blisters should be applied over the abdomen, or pustulation produced 
with tartar emetic ointment, according to the condition of the patient, and 
continued till the tenderness subsides. After having used the counter- 
irritants for a reasonable time, strong iodine ointment should be applied 
twice each day, so as to use at least an ounce per week ; and the patient 
should be directed to wear a flannel next the skin, and so applied as to 
cover the whole abdomen, in order to promote perspiration. 

The patient should also be directed to wear a flannel wrapper, to sleep 
in flannel sheets, and to take extreme care to keep the feet warm and 
dry. To promote a healthy action of the glandular and lymphatic 



372 DISEASES OF THE DIGESTIVE SYSTEM. 

systems and to prevent effusion, with its consequences, five grain doses 
of the iodide of potassium may be given in simple syrup, three times per 
day and continued for a long time. Should an anodyne become neces- 
sary to quiet restlessness and procure sleep ; the solid or fluid extract of 
hyoscyamus, or conium in moderate doses will generally do best. The 
bowels should be kept gently relaxed by small doses of cream of tartar, 
administered occasionally during the whole course of the disease ; a tea- 
spoonful may be given at evening if the bowels have not moved during 
the day. 

If, as generally happens, the blood becomes weak from defective 
chymification during the latter stages of this disease, some preparation 
of iron is clearly indicated. The syrup of the iodide of iron may be 
given in ten drop doses, three times per day, as a tonic and alterative, 
and continued for a long time. Or, in case that should disagree, the citrate 
of iron maybe given instead, in two or three grain doses after each meal. 

In tuberculous cases, in addition to the iodide of potassium and some 
preparation of iron, the cod-liver oil may be indicated, and should be 
given in moderate doses an hour after each meal. 

The food during the early stages of chronic peritonitis should be mild 
and unirritating and easy of digestion; but during the latter stages, 
bread and milk, with meats, may be freely allowed. Great regularity 
should be observed in taking food, and every precaution taken to guard 
the general health, that the system may be able to bear up under this 
extensive, insidious and complicated variety of chronic peritoneal inflam- 
mation. By a proper and judicious treatment, faithfully applied, I 
believe that even tuberculous cases may be retarded in their progress, 
and many simple cases permanently cured. 

SECTION XYII.— ACUTE HEPATITIS. 

By acute hepatitis I mean acute inflammation of the liver; which, it 
will be remembered, is a large conglomerate gland appended to the ali- 
mentary canal, and occupying the right hypochondrium. 

The liver is placed obliquely in the abdomen ; its convex surface being 
upwards and forwards, and its concave downwards and backwards. It is 
in relation superiorly and posteriorly with the diaphragm, and inferiorly 
with the stomach, duodenum, colon, and right kidney; its free border 
corresponding with the lower margin of the ribs. 

The liver is supplied with arterial blood by the hepatic artery, and it 
also receives, through the vena porta, the blood from the chylopoietic 
viscera taken up by the gastric, splenic, superior and inferior mesenteric 
veins. 

The liver probably separates impurities from the blood, which passes 
through it along the vena porta, on its way to the general venous circu- 
lation, and it also secretes the bile, which is conveyed along its excretory 
duct, and emptied into the duodenum, along with the pancreatic fluid; 
this fluid being essential to chylification. The blood introduced into the 
liver by the hepatic artery and vena porta, is taken up by the hepatic 
veins, and carried by them to the vena cava ; its impurities, as well as 
the bile, having been drained off. and returned to the alimentary canal. 



ACUTE HEPATITIS. 373 

The liver, thus situated and constituted, with its firmness of structure, 
and great vascularity, is liable to severe congestions, and inflammations; 
the acute form of which we will now proceed to consider. 

Symptoms. — Acute hepatitis generally makes its attack suddenly, and 
with considerable violence, especially in marshy or miasmatic localities. 
The disease generally commences with chills, and a pain, either acute, or 
dull and heavy, in' the right hypochondrium ; accompanied with a sensa- 
tion of tightness across the abdomen, some difficulty in breathing, and a 
disinclination to the recumbent posture; the patient generally feeling 
easiest while sitting, slightly inclined forwards, and to the right side. 

Sometimes the attack is less impetuous ; the patient complaining of a 
feeling of tightness in the right hypochondrium and epigastric regions, 
with very slight febrile symptoms, for some time, before anything serious 
is apprehended. More or less fever, however, is developed in all cases ; 
and sometimes this precedes any well marked symptoms of the local in- 
flammatory affection. 

The pain attending acute inflammation of the liver, frequently extends 
to the breast, clavicle, and shoulder of the right or left side. And in 
some cases, these sympathetic pains are more severe, than those in the 
liver itself. If the inflammation be confined to the substance of the 
liver, the pain is of a dull, heavy, aching character; but if the inflam- 
mation extend to its peritoneal coat, the pain becomes acute, and some- 
times very severe. 

If the right lobe of the liver be the seat of the inflammation, the pain 
and tenderness is in the right side, and the patient complains of pain in 
the right shoulder. If, however, the left lobe be the part inflamed, there 
is pain and tenderness in the epigastrium; and more or less pain is felt 
in the left shoulder. When the inflammation occupies the lower portion 
of the right lobe, there is apt to be more or less intestinal disturbance ; 
but if the superior portion of the lobe be the seat of the inflammation, 
there is generally considerable pulmonary derangement. Finally, in 
cases in which the inflammation is of the left lobe, there is usually con- 
siderable gastric disturbance, with nausea and bilious vomiting. 

There is generally in this disease, a yellow appearance of the eyes, 
and also of the skin, of the chest, neck and face. And the urine is 
generally charged with more or less bile being of a deep yellowish color. 
The thirst too is urgent, and the skin hot and dry. The pulse is usually 
full, active, and firm ; but if the inflammation extend to the peritoneal 
coat of the intestines or stomach, it may become small, tense, and quick. 

The tongue is either smooth and glossy, or else it is coated with a 
white or yellowish fur, and in this case the mouth has a dirty bitter taste. 
The bowels are apt to be constipated, but a looseness with dysenteric or 
serous discharges may attend from the very first, produced probably by 
congestion of the liver interrupting the portal circulation. The brain is 
apt to sympathize with the inflamed organ, often giving rise to slight 
mental disturbance. 

Acute hepatitis rarely continues beyond the seventh day without ter- 
minating either in resolution or suppuration. When suppuration takes 
place the pain may become less, there is a sense of weight and throbbing 
in the region of the liver, with rigors, night sweats, sinking, anxiety, 
oppression, and a cold clammy skin. 



374 DISEASES OF THE DIGESTIVE SYSTEM. 

Sometimes large abscesses form in the liver as the inflammation sub- 
sides, and if the liver has formed adhesions with the parietes of the abdo- 
men, the abscess may point externally, and the matter be safely dis- 
charged, and recovery follow. The matter may point in the superior 
part of the liver, which, having formed adhesions with the diaphragm, 
the matter enters the thorax. In this case it may pass by ulceration 
into the bronchial tubes and be expectorated, but care should be taken 
not to mistake the bronchial secretion sometimes set up from sympathy, 
or from an extension of the inflammation in hepatitis, for a purulent 
expectoration from the liver. 

In other cases the liver forms adhesions with the intestines, and the 
abscess bursts into the alimentary canal, and is discharged by stool, a 
final recovery being the result, or the hepatic abscess may burst into the 
cavity of the abdomen, and the case thus terminate fatally. — In cases of 
hepatic abscess in which pure pus is discharged, it has generally col- 
lected between the glandular substance and its peritoneal covering ; but 
if the matter discharged be of a dark gray color, it has probably come 
from the interior of the liver, or from the glandular portion of the organ. 

Acute hepatitis may also terminate in gangrene, but in fatal cases, the 
substance of the liver may become softened and of a darkish color. 

Anatomical Characters. — In cases of hepatitis, in which death has 
taken place early, if the peritoneal coat has been involved in the inflam- 
mation, it is found red, more vascular, and perhaps thickened, and some- 
times covered with coagulable lymph, advancing more or less towards 
organizatian. If the parenchyma has been inflamed, it is found con- 
gested with blood, enlarged, and softer than in health, and on being cut, 
there is apt to be an oozing of blood, which appears to have occupied 
small cavities in the substance of the gland. 

If the patient has died at an advanced stage of the disease, abscesses 
are found occupying the substance or surface of the liver. If the abscess 
occupies the substance of the gland, the tissue about the abscess is found 
more vascular than at other points, and the abscess contains a sero-puru- 
lent fluid, mixed with the softened matter of the gland. 

In some cases but one abscess is found, while in others they are quite 
numerous, and in some rare instances, nearly the whole gland is converted 
into a sero-purulent mass, contained in its investing peritoneal membrane. 
The pus may appear quite natural, if it only occupies the surface of the 
gland, but otherwise it is apt to be of a reddish, green, or dark appear- 
ance, being mixed with bile, and perhaps more or less of the disor- 
ganized tissue of the gland. 

Diagnosis. — Hepatitis may be confounded with pleurisy, pneumonia, or 
gastritis, from each of which, however, it may be distinguished by care- 
ful attention to the following differences. 

In pleurisy the cough and oppression in the chest are more severe than 
in hepatitis; and besides, in hepatitis the patient generally rests on the 
affected side, while in pleuritis, the patient lies on the well side. In 
hepatitis the tenderness is in the epigastrium, or right hypochondrium, 
while in pleurisy the tenderness is felt in the intercostal spaces. 

From pneumonia, hepatitis may be distinguished by attention to the 
manner in which the respiration is performed. It being carried on in 



ACUTE HEPATITIS. 875 

pneumonia mainly by the abdominal muscles, while in hepatitis it is 
performed almost entirely by the intercostal muscles. 

Erom gastritis, this disease may be distinguished by the full, hard 
pulse of hepatitis, while in gastritis, it is generally more or less con- 
tracted and weak. And besides in gastritis, there is a good deal of 
prostration from the first, and obstinate vomiting on taking anything 
into the stomach, while in hepatitis the vomiting is not so constant, and 
there is not so much prostration at the commencement of the disease. 

From the passage of gall stones, hepatitis may be distinguished by 
the fever, by the continuous pain, and by the position of the patient, in 
hepatitis the patient inclining a little forward and to the right side, 
while in the passage of biliary concretions, the patient is easiest when 
the body is bent forward on the pelvis. 

Thus may hepatitis be distinguished from the various aifections with 
which it has some symptoms in common. 

Causes. — The causes of acute hepatitis are various, but it is probable 
that the paludal poison, heat, or atmospheric viscissitudes, together with 
the use of intoxicating liquors, and tobacco, and other species of intem- 
perance, are by far the most frequent causes. 

We have seen that koino-miasmata, has a debilitating affect upon the 
brain and nervous system, and that when the brain and nervous system 
become thus prostrated, the functions of the different organs become 
impaired, and none more sensibly than that of the liver. When, there- 
fore, this agent acts upon the system through the blood, the liver becomes 
torpid and congested, and this congestion irritating the capillaries of the 
arteries, veins, and portal vessels, provokes inflammation. 

Atmospheric vicissitudes produce hepatitis, in part probably, by the 
sympathy that exists between the action of the skin and liver. And 
hence, during the autumnal season, or when we have hot days and cool 
nights, the perspiration becomes suddenly checked, during the night, and 
the action of the liver more or less torpid. As a consequence of all this, 
the portal vessels become congested, and their capillaries in the liver, 
which congestion provokes irritation and inflammation, and this is pro- 
bably the most frequent cause of hepatitis. It is probable, however, that 
the paludal poison and heat, or atmospheric vicissitudes, combine in 
most cases, to produce acute hepatitis. 

It is probable that tobacco produces hepatitis, by its debilitating effects, 
in a manner similar to the paludal poison. But intoxicating liquors, as 
they are probably in part taken up by the portal vessels, and carried 
through the liver into the circulation, may act as a direct irritant to the 
capillaries of the liver, and thus produce hepatatic inflammation. 

Besides the causes already enumerated, it is probable that violent 
exercise, injuries of the right hypochondrium, wounds of the head, the 
passages of biliary calculi, the abuse of mercury, the translation of gout 
or rheumatism, the suppression of hemorrhoids, terror, mental despon- 
dency, and various other causes may produce acute hepatitis. 

Pathology. — It appears probable that direct irritants in the blood, act 
primarily upon the portal veins, and their capillaries, in consequence of 
which they become congested and inflamed, and very soon all the minute 
arteries, veins, and capillaries of the liver, and with them its whole 
structure. 



376 DISEASES OF THE DIGESTIVE SYSTEM. 

In hepatitis, produced by agents which act indirectly through the 
system, the congestion, irritation, and inflammation, whether active or 
passive, may commence in any of the capillaries of the organ, and ex- 
tend, soon involving its whole structure, always producing, however, con- 
gestion of the portal vessels. 

Treatment. — If this disease be attended to in its incipient stage, great 
hope may be entertained of arresting the inflammation. The feet should 
be placed in warm water, and if there be chilliness, warm stimulating 
friction may be made along the spine. After this, a few ounces of blood 
should be taken from the right side of the spine, opposite the liver, and 
also from the right hypochondrium. 

A full dose of calomel and castor oil should be administered, and the 
patient directed to drink freely of warm sage tea. Or, in case the mer- 
curial is contra-indicated, two or three grains of podophyllin may be 
given with the oil, instead of the calomel. In this way incipient hepa- 
titis may sometimes be arrested: the warm foot-bath taking off the 
undue pressure on the brain ; the warm friction along the spine equal- 
izing the circulation ; while the cupping relieves any irritation that may 
have been set up in the spine or liver ; and the cathartic relieves the 
congestion of the portal vessels. 

But unfortunately we do not always see such cases thus early, or, if 
we do, we may not always succeed so readily in arresting the inflamma- 
tion. In cases that have passed on till the inflammation is fully estab- 
lished, and a high febrile reaction is set up, the same measures, except 
warm friction to the spine, should be resorted to, as helps ; but we may 
be under the necessity of resorting to general bleeding, and other mea- 
sures, to prevent the most fearful consequences. 

After getting the effects of the warm foot-bath, general bleeding, cup- 
ping, and a cathartic; in such cases, a large blister should be applied 
over the right hypochondrium, and kept discharging. If the inflamma- 
tion persists, three grains each of calomel, Dover's and James's powders 
may be given, every four or six hours ; and this treatment may be con- 
tinued till an impression is made on the disease, or ptyalism is produced, 
the bowels being moved two or three times every twenty-four hours, by 
small doses of the sulphate of magnesia. 

If an impression be made on the disease, or ptyalism is produced, the 
calomel should be omitted, and the other treatment continued, modified, 
of course, by the indications as they arise. Should suppuration take 
place, and the matter approach the surface, a poultice should be applied, 
and the matter evacuated, as soon as it is in a fit condition. In such 
cases, after matter has formed, the iodide of potassium should be admi- 
nistered, in five grain doses, three times per day, before eating, and con- 
tinued for a long time. 

If an anodyne be indicated to quiet restlessness and irritability, the 
solid or fluid extract of conium will generally do best, or the solid or 
fluid extract of conium and taraxacum may be combined, and given in 
moderate doses after each meal, and continued for a time as an alterative 
and anodyne. If the digestion is bad, and the stomach distended with 
wind, a mild tonic bitter of columbo in cold water, or half a drachm of 
the fluid extract may be administered before or after each meal for a 
time. 



CHRONIC HEPATITIS. 277 

During the debility which . follows extensive suppuration, the syrup of 
the iodide of iron may be given in ten drop doses three times per day. 
During the inflammatory stage of the disease, the nourishment may con- 
sist of crust coffee with a little milk, but later, a plain, digestible and 
nourishing diet may be allowed. 

SECTION XVIII.— CHRONIC HEPATITIS. 

By chronic hepatitis I mean a slow or protracted inflammation of the 
liver. Chronic inflammation of the liver is generally of its glandular 
structure ; and when not the result of the acute form, is usually rather 
insidious in its attack. 

Symptoms. — Chronic hepatitis commences usually with symptoms of 
dyspepsia. The patient complains of irregular appetite and acidity of 
the stomach, as well as of colic pains, nausea, and a sense of fullness in 
the region of the stomach. In some instances there is pain and perhaps 
tenderness in the epigastrium or right hypochondrium, and pain in the 
right or left shoulder ; but very often no pain is experienced in the 
region of the liver, unless firm pressure be made on the surface. In 
most cases firm pressure produces an uneasiness, and by careful exami- 
nation the liver may be found enlarged, and projecting below the short 
ribs. 

If the superior portion of the right lobe be the part involved, the 
lungs may suffer considerably, and there may be more or less cough. 
When the inflammation is confined to the lower portion of the right lobe, 
there is apt to be intestinal disturbance, with perhaps a diarrhoea or 
dysenteric discharges. Finally, when the left lobe of the liver is the 
part inflamed, the stomach generally suffers more or less ; and nausea 
with distressing vomiting may occur. The pain, if the inflammation be of 
the right lobe, may extend to the right shoulder, but if the hepatic inflam- 
mation be of the left lobe, it is generally referred to the left shoulder. 
In most cases of chronic hepatitis the eyes, as well as the skin of the 
face, neck and chest, become tinged of a yellowish hue. 

The bowels may be constipated with occasional diarrhoea; the dis- 
charges being dysenteric or else of a dark muddy appearance. The 
urine is generally highly tinged with bile. The tongue is white and 
dry, the taste bitter ; and in advanced stages of the disease, the gums 
are apt to assume a firm hardened appearance. The skin in this 
disease is dry and harsh, and as it progresses the patient loses flesh, 
slight febrile exacerbations come on towards evening with heat in the 
palms of the hands and soles of the feet; and unless the disease be 
arrested, it may terminate in suppuration, emaciation and death. 

Anatomical Characters. — Various morbid appearances are presented 
on the examination of subjects dead of this disease ; among which are 
induration, softening, suppuration, &c. 

Induration is probably the result of the exudation of coagulable lymph 
into its tissue ; and it may be partial, or it may extend throughout the 
whole gland. The indurated liver may be either enlarged or contracted, 
and it is generally of a yellowish color. 

While induration is occasionally found, partial or general softening is 



378 DISEASES OF THE DIGESTIVE SYSTEM. 

a much more frequent morbid condition, following this disease. In cases 
of chronic hepatitis, in which the gland is thus found softened, the por- 
tion involved is generally of a dark reddish color, and it may be only 
slightly softened, or it may be reduced to a mere pulp, or a portion of it 
at least. 

Besides softening and induration, as morbid conditions in this disease, 
abscesses are frequently found ; in some cases large and single, but in 
others, smaller and quite numerous. Various other morbid appearances 
may be presented, but softening, induration, or abscesses, are the ap- 
pearances most frequently presented on the post-mortem of subjects dead 
of this disease. 

Causes. — Chronic inflammation of the liver is frequently the result of 
the acute form of the disease. Or it may arise from a slow operation of 
the causes which produce acute hepatitis ; such as heat, or atmospheric 
vicissitudes, the paludal poison, intoxicating liquors, tobacco, and va- 
rious abuses of the system, such as masturbation, excessive venery, &c. 
It is also sometimes the result of direct injury, or the metastasis of gout 
or rheumatism, or it may arise from the suppression of the hemorrhoidal 
or other accustomed discharges. 

Treatment. — The indications in the treatment of chronic hepatitis may 
depend very much on the constitution of the patient. The cause should 
be sought out and removed, if possible, at first, in all cases. And if a 
mercurial is not from any cause contra-indicated, two grains of the blue 
mass may be given, morning and evening, with an equal quantity of the 
extract of conium, as an alterative and anodyne, and continued for a few 
days ; the bowels being kept regular by drachm doses of the fluid ex- 
tract of taraxacum, after each meal. If from delicacy of constitution, 
or from any other cause, a mercurial be contra-indicated, one-third of a 
drachm of the fluid extract of the Leptandra Yirginica, or else of the 
podophyllum peltatum, with ten drops of the fluid extract of the conium 
maculatum, may be given after each meal, for a time, as an alterative, 
anodyne, &c. 

Cups should be applied along the right side of the spine, opposite the 
liver, and also over the epigastrium and right hypochondrium, and more 
or less blood taken at first. Dry cups may then be repeated every day 
or two, or blisters may be applied, or pustulation produced by tartar 
emetic ointment, till the inflammation be subdued. 

After having continued the mercurial for a reasonable time, in cases 
in which it is indicated, it should be omitted, and five grain doses of the 
iodide of potassium given three times per day, with the fluid extract of 
taraxacum, the podophyllin, or leptandrin, being given as an alterative, 
if an alterative be still required. In cases in which a mercurial is not 
used, the iodide of potassium may be commenced with as soon as the 
pain and tenderness subside, and it may be given in connection with the 
fluid extracts of the leptandra or mandrake, conium and taraxacum, or 
such of them as may be indicated, till the disease is subdued. Should a 
bitter tonic be indicated, a cold infusion of columbo, or moderate doses 
of the fluid extract, may be given for a time after each meal. 

The nitromuriatic acid foot-bath may be of service in obstinate cases 
of chronic hepatitis. Equal parts of the nitric and muriatic acids may 



SPLENITIS. 379 

be combined -with an equal quantity of water, and of this an ounce may 
be put into a gallon of warm water, and the feet and legs kept in it for 
twenty or thirty minutes, before going to bed each night, for two or three 
weeks. By thus removing the cause, and keeping up an alterative course, 
with counter-irritation, and fulfilling the indications as they arise, with 
safe remedies judiciously applied, many troublesome cases of chronic 
hepatitis may be either palliated or permanently cured. 

The diet, during the early stages of this disease, must be of a plain, 
unirritating character; one of the best articles of which is wheat or 
Indian bread, and milk. Later, the diet may be highly nourishing, but 
digestible, and may consist of bread and milk, meats, &c, taken with 
regularity. 

The patient should wear flannel next the skin, and sleep in flannel 
sheets ; and he should keep in a temperature that is agreeable, and by no 
means be exposed to dampness, or suffer from chilliness or cold. Such, 
then, are the principles which are to guide us in the treatment of chronic 
hepatitis; subject, however, to modifications, from the variety and degree 
of the hepatic inflammation. 

SECTION XIX.— SPLENITIS. 

By splenitis I mean inflammation of the spleen, which is an oblong, 
flattened organ, of a bluish red color, situated in the left hypochondrium. 
The spleen is in relation superiorly and on its external surface with the 
diaphragm ; by its concave surface, with the stomach, pancreas, and left 
kidney ; and by its lower end with the transverse colon. It is invested 
by the peritoneum, and by a yellowish elastic tissue, which penetrates 
the organ, forming sheaths for its vessels. 

The spleen is supplied with blood by the splenic artery, a division of 
the cceliac axis, and is a very vascular organ, even its lymphatics being 
very numerous and of a large size. The veins of the spleen pour their 
blood into the splenic vein, which is one of the principal trunks of the 
portal vein; its lymphatics terminate in the lumbar glands, and it is 
supplied with nerves by the splenic plexus. It is probable that the 
spleen serves, as Professor Draper has suggested:* "As a receptacle for 
any excess of blood" in the portal vessels; and that it also aids in "the 
dissolution of the disorganizing blood-cells, preparatory to the action of 
the liver, in which hsematin is to be converted into the coloring matter 
of the bile." 

The spleen thus constituted and situated, is liable to become inflamed ; 
the symptoms of which we will now proceed to consider : 

Symptoms. — Inflammation of the spleen generally commences with 
chills or coldness, followed by febrile excitement, more or less marked, 
and it is attended with pain and tenderness to external pressure in the 
left side, immediately under the false ribs. The left hypochondrium is 
generally fuller than in health, and there may be pain in the left and 
perhaps the right shoulders. 

The white of the eyes are apt to assume a bluish appearance, and the 
skin may assume a yellowish tinge. In consequence of the relation of 

* See Draper's Physiology, pages 211 and 212. 



380 DISEASES OF THE DIGESTIVE SYSTEM. 

the spleen to the stomach, liver, lungs, left kidney and colon, more or 
less derangement in the functions of some or all these organs or parts is 
lable to occur in splenitis. 

An oppressive sensation is apt to be experienced in the stomach, with 
dyspeptic symptoms, and perhaps nausea and vomiting. By an extension 
of the irritation to the lungs, through the diaphragm, there may be pro- 
duced troublesome cough, and hiccough may also attend, with dyspnoea, 
palpitation of the heart, &c. The liver or kidneys may become func- 
tionally deranged, and the bowels may become constipated ; or there may 
be a looseness of the bowels, with serous, bloody, or dysenteric discharges. 

Splenitis may be of an active, or passive character; and it may assume 
an acute or chronic form. The acute active variety of splenitis generally 
occurs in sthenic constitutions, while the passive and chronic varieties are 
apt to occur in the asthenic, or in patients worn down by some miasmatic, 
or other variety of disease, deranging the portal circulation. 

Chronic splenitis is attended with a feeling of uneasiness, and fullness 
in the left hypochondrium, and sometimes with pain and tenderness on 
pressure. There is also apt to be pain in the left shoulder, and on ex- 
amination, the spleen is found considerably enlarged; forming a more or 
less prominent fullness in the left hypochondrium. 

In chronic cases, the functions of the stomach, liver, lungs, heart, 
kidney, and intestines, are as liable to suffer as in the acute form of the 
disease, though generally in a less degree. The disease seldom continues 
in its acute form, without terminating in resolution, or suppuration, longer 
than one or two weeks ; but it may assume a chronic form, or it may be 
so from the first, in which case it may continue on for months, or even 
years. 

Anatomical Characters. — If the patient has died early, the organ is 
found enlarged, and of a darkish color, being also more or less softened. 
If the patient dies later; pus, mingled with blood, is found, either infil- 
trated, or collected in cavities ; sometimes occupying most of the organ, 
or filling completely its investing capsule. 

In chronic cases, the spleen is generally found enlarged, and either 
hypertrophied, indurated or congested ; or else softened with purulent or 
bloody infiltration. Its proper coat is often found cartilaginous or osseous, 
and its peritoneal investing membrane, adhering to the stomach, intestines, 
or kidney. 

Diagnosis. — Splenitis may be distinguished from hepatitis, by the pain, 
tenderness, and fullness in the left side, by the bluish appearance of the 
eyes, and by the absence of the marked jaundiced appearance, so common 
in hepatitis. 

Causes. — Splenitis may be produced by violent exercise, by injuries, 
by mental emotion, and by the metastasis of other disease, or the sup- 
pression of some accustomed discharge. Splenitis too is often produced 
by miasmatic, and other affections, which interrupt the portal circulation. 

Chronic splenitis may be the result of the acute form of the disease. 
But it most frequently occurs from miasmatic influences, or from the chills 
or congestions which attend intermittent, remittent, or congestive fevers. 

Treatment. — In acute inflammation of the spleen, cups should be ap- 
plied to the left hypochondrium, and along the left side of the spine, 



DYSPEPSIA. 381 

opposite the organ ; and from four to six, or eight ounces of blood taken. 
A mercurial or saline cathartic should be administered ; the warm foot 
bath resorted to, and the cupping repeated, if necessary, or blisters ap- 
plied, till the inflammation be subdued. 

In chronic cases cupping over the left hypochondrium, and along the 
spine, without taking much if any blood, should be resorted to at first, 
and then blisters may be applied to the left hypochondrium, or pustula- 
tion produced with tartar emetic ointment. A blue pill may be given at 
evening, for a few days, and a teaspoonful of the sulphate of magnesia 
in the morning, and then five grain doses of the iodide of potassium may 
be given three times per day, before each meal, and continued till the 
fullness entirely disappears. After counter-irritants have been used for 
a reasonable time, iodine ointment may be freely applied. The patient 
should wear flannel next the skin, should take a plain, digestible, and 
nourishing diet, and if the splenitis be the result of or complicated with 
other affections, such affections should be judiciously removed. 

SECTION XX.— DYSPEPSIA— [Indigestion.) 

By dyspepsia, from Sv?, "with difficulty," and rtsrctu, "I concoct," I 
mean difficult, disturbed, or imperfect digestion, from whatever state or 
condition it may arise ; the indigestion being the predominant symptom. 
In order to appreciate dyspepsia, or indigestion, let us take a glance at 
the processes by which healthy digestion is performed, and then we may 
be able to appreciate indigestion, in its various forms. 

It is necessary for healthy digestion, that the food be of a proper 
quality, that it be taken at regular hours, and that it be well masticated, 
and moistened with saliva, before it passes into the stomach. In the 
stomach it must meet with sufficient gastric juice to thoroughly dissolve 
it, and the stomach must possess sufficient muscular power to carry it 
into the intestines, after it is converted into chyme. In the duodenum 
the chyme must meet with sufficient bile and pancreatic juice, to dissolve 
the fatty portions of the chyme, that it may be mixed with the albumen, 
and form a milky substance, or chyle, of a character fit to be taken up 
by the absorbents of the small intestines. The mucous membrane of the 
alimentary canal, and especially of the small intestines, must be in a 
healthy state, so that the lacteals may be able to take up the chyle, and 
the muscular coat of the intestines must also possess tone sufficient 
to carry along, and expel from the bowels, the residual matter of the 
food. 

And in order for the chyle, thus prepared and taken up by the intes- 
tinal lymphatics, to be taken into the system and appropriated to its 
use, the mesenteric glands, through which the lacteals pass, must be in 
a condition to aid in converting the fat and albumen of the chyle into 
fibrin, which in a healthy state passes to the thoracic duct, and thence 
to the general circulation, and to every part of the system. Such then 
is healthy digestion. 

Now any deviation from this natural process of digestion is indiges- 
tion, however slight or trifling it may be, and if continued for any length 
of time, is generally connected with a weak, relaxed, and debilitated 



382 DISEASES OF THE DIGESTIVE SYSTEM. 

condition of the mucous membrane, and muscular coat of the stomach, 
or else with an irritated, excited, or inflamed condition of the mucous 
and muscular coat of the stomach and intestines. 

Let us now bear in mind that dyspepsia may depend upon directly op- 
posite conditions of the alimentary canal ; in the one case the mucous 
and muscular coats of the stomach and intestines, being in a weak, relaxed 
and debilitated condition, while in the other, they are in a morbidly irri- 
tated, excitable or inflamed state. With these considerations, let us pro- 
ceed to inquire into the symptoms which are developed in dyspepsia, in 
its various forms. 

Symptoms. — In that variety of indigestion in which there is a debili- 
tated and relaxed condition of the stomach and intestines, with no 
marked irritation, or inflammation, the appetite is generally poor, and 
often entirely destroyed. The patient is troubled with flatulence, acid 
eructations, and colic pains ; the mind is depressed and languid ; the 
bowels are usually constipated, and if the disease be protracted there is 
almost always a marked degree of despondency and general emaciation. 

In cases of indigestion in which there is more or less irritation of the 
mucous membrane of the stomach and intestines, and a morbidly excita- 
ble condition of their muscular coat, the appetite is frequently morbidly 
increased, but no sooner is the food in the stomach, than the irritated 
organ, by an excited morbid action, hurries it along into the intestines 
in a partially digested state. Immediately after eating, the pain in the 
stomach subsides for an hour or so, when it usually returns and con- 
tinues, more or less severe, for two or three hours ; then it gradually 
subsides, and gives place to a gnawing or morbid sensation of hunger, 
which goes on increasing till it becomes exceedingly distressing, or till 
food is taken, when there is again a temporary abatement. 

The patient has frequently a sour stomach, with eructations ; there is 
yellowness of the skin, and sometimes of the eyes ; there is distress in 
taking very cool or very warm drinks, and not unfrequently there is an 
appetite for some particular kind of food for a time, and then no relish 
for any. In this way the patient passes on, with tedious days and rest- 
less nights, with great physical and mental irritability, till the most in- 
timate friends can hardly be tolerated, and existence itself becomes 
almost a dread. Such are the most prominent symptoms of dyspepsia, 
attended with nervous irritability, affecting especially the stomach, but 
generally more or less the whole system, if the disease continues for a 
long time. 

Indigestion, attended with inflammation of the mucous membrane of 
the stomach, is generally attended with an irregular appetite, sour sto- 
mach, nausea, tenderness to external pressure, a yellow tinge of the skin, 
a red and dryish tongue, thirst for cool drinks, irregularity of the bowels, 
and more or less general nervous irritability. There is distress or pain 
in the stomach immediately after eating, or taking warm drinks, which, 
however, gradually subsides as the food passes from the stomach. Any 
very stimulating food or drink greatly aggravates the distress, and in- 
creases the morbid thirst. 

The pulse is small, tense and quick, the skin harsh and dry to the feel ; 
there is pain in the head, and frequently along the spine, and nausea is 



DYSPEPSIA. 383 

produced if firm pressure be made on the epigastrium. The bowels are 
either constipated or very much relaxed ; the food frequently passing in 
an undigested state. The urine is scanty, and of a yellowish appear- 
ance, indicating more or less functional derangement of the liver, or ob- 
struction to the free passage of bile into the intestines ; perhaps from an 
extension of the inflammation along the duodenum to the mouth of the 
bile duct. 

Thus, then, we have the symptoms developed in dyspepsia in its three 
prominent forms. But it must be remembered that while every case of 
dyspepsia may come under one of these heads, there is an almost endless 
variety of degrees in each. And also, that the three varieties may be 
developed in the same case, beginning with the relaxed or debilitated, 
and ending with the inflammatory, or the reverse ; especially if the im- 
prudence producing it be continued, and the case neglected. 

Causes. — The causes of dyspepsia are various, but the most frequent 
are irregularity and imprudence in taking food, improper exercise, &c. 
The stomach in a healthy state will call for the kind and quantity of 
food that the system requires ; so that in a state of health if its calls 
were always properly heeded, it would be a safe guide, as to the quality 
and quantity of food to be taken. Dyspepsia is often contracted in 
early life, and frequently in early childhood, or even infancy, and the 
following is, according to my observation, the manner in which it is 
generally brought about. 

Infants are allowed to nurse at irregular hours, or when they cry, in 
order to pacify them, and at the very time when the stomach is least able 
to digest its food. By this imprudence and irregularity many infants get 
dyspepsia, attended with sour stomach, vomiting, &c. 

After children begin to take solid food, they are often allowed to eat 
a piece, to allay the morbid appetite which this imprudence has produced, 
or to please the taste, or to allay anger, when the system is not in need 
of food, or the stomach in a condition to digest it. 

In this way, a habit of eating at irregular hours, or between meals is 
contracted, and being continued till the child grows to maturity, tobacco 
chewing or smoking is taken up to cure the dyspepsia. Now the system 
once under the intoxicating effects of this narcotic poison, the natural 
appetite is lost, and the mucous and muscular coats of the stomach be- 
come narcotized, debilitated, and incompetent to digest food enough to 
supply the actual wants of the system, and that little is but poorly done. 
In this way is that variety of dyspepsia, attended with a debilitated con- 
dition of the mucous and muscular coats of the stomach, very frequently 
brought about. 

If now, as generally happens in such a state, the system becomes de- 
bilitated, and the appetite morbidly craving, the system calls for more 
food than the stomach can digest. An extra amount of food is taken, 
but the stomach fails to digest it properly. This undigested mass acts 
as an irritant to the mucous membrane, and the muscular coat also be- 
comes irritated, in consequence of which the undigested mass is carried 
into the intestines, and acts as an irritant to the alimentary mucous 
membrane. Thus it is that dyspepsia, marked by irritability of the sto- 
mach, is very often produced. 



384 DISEASES OF THE DIGESTIVE SYSTEM. 

If now, as frequently happens, this manner of taking food, and this 
imperfect process of digestion continue, with, as occasionally happens, 
the use of intoxicating liquors, the mucous membrane of the stomach be- 
comes congested and inflamed, and the muscular coat highly irritated, 
and this constitutes the third variety of dyspepsia, or that in which there 
is inflammation of the mucous membrane of the stomach, and a morbidly 
irritable condition of the muscular coat. 

There are various other causes of the different varieties of dyspepsia, 
such as want of, or improper exercise ; eating unwholesome food, eating 
too fast, drinking too much hot tea or coffee, drinking too much at meals, 
or moistening the food in the mouth with drinks, instead of saliva, in- 
tense mental application immediately before or after eating, and various 
other like imprudences. 

Treatment. — As we now proceed to the consideration of the treatment 
of dyspepsia, let us first examine those rules or regulations which are 
adapted to all cases of indigestion, and then we will inquire into the 
peculiar indications in each variety. 

All dyspeptics, as well as every body else, should be directed to take 
only wholesome, digestible food, and that at regular hours, three times 
per day; and no dyspeptic or other person should be allowed, on any 
account, to take food between meals, even though the stomach can bear 
but little food at a time, except in the case of infants, and persons re- 
duced by disease, in which case nourishing drinks may be allowed. 

This regulation is absolutely necessary, not only for dyspeptics, but 
for those in health, in order to give the stomach time to rest after digest- 
ing, or attempting to the preceding meal. If this rule be rigidly adhered 
to, very much will be accomplished by that alone, to prevent and cure 
dyspepsia. 

Food should be taken slow, and be well masticated, and the patient 
should be directed to allow the food to be moistened in the mouth by the 
saliva, and not to drink too much during meals. If this rule be rigidly 
adhered to, the food will go into the stomach in a fit condition for the 
action of the gastric juice. And by avoiding too much drink, the gastric 
juice will not be too much diluted, to dissolve the food which is taken. 

The dyspeptic should be directed to take enough exercise, and if pos- 
sible at some employment calculated to occupy both the body and the 
mind. But active exercise should be suspended for at least one hour 
before and after eating, in order to give the stomach the full benefit of 
the energies of the system during the effort at digestion. If the appe- 
tite be morbid, and therefore not a guide as to the quality, kind or quan- 
tity of food to be taken, the judgment of the patient, together with the 
advice of his physician, must be the dictator in these respects, till such 
time as the appetite becomes natural, and its calls an infallible guide 
when it should be rigidly adhered to. 

Clean cold water should be recommended for all dyspeptics who have 
not become the slaves of tea and coffee ; being the most natural and 
wholesome drink for man, as it is for the whole animal creation. But in 
cases in which tea and coffee cannot be suspended by the dyspeptic, on 
account of long continued use, they should be taken with moderation and 
not too hot. Tobacco and intoxicating liquors are poisons and should 



DIARRH(EA. 385 

not be used by any one ; the dyspeptic, therefore, who has been made so 
by their use, should be directed to abandon them, as fast as it can be 
done, without producing delirium tremens. 

If these rules were obeyed, we should get few cases of dyspepsia, and 
if rigidly enforced with the dyspeptic, it would entirely cure very many 
cases and greatly relieve those it might fail to cure. It appears to me 
utter folly to prescribe medicines for indigestion or any other disease, 
while a violation of these and other laws of health have not only produced, 
but are keeping up the morbid condition. But having corrected the 
habits of the dyspeptic, various remedies may be of service in correcting 
the morbid conditions which the imprudence has produced. 

In dyspepsia attended with a weak and debilitated condition of the 
stomach, a good nourishing diet of animal food may be allowed ; and the 
tone of the stomach may be improved by moderate doses of the cold in- 
fusion, or the fluid extract of columbo, taken three times per day after 
each meal ; and if the blood is weak, wo grains of the ammoniated 
citrate of iron may be taken in solution, at or before eating, three times 
per day. 

In that variety of dyspepsia in which the stomach is in an irritable, 
but not in an inflamed condition, the food should be mild and nourishing, 
but not very stimulating. To allay the nervous irritability of the 
stomach and correct acidity in such cases, a pill of two grains each of 
the extract of hyoscyamus and the subnitrate of bismuth may be given 
for a time after eating, morning, noon and night. If there be a weak 
state of the blood, the ammoniated citrate of iron may be given in two 
grain doses in solution, three times per day and continued for a time. 

In cases of dyspepsia attended with inflammation of the mucous coat 
of the stomach, the food should be of the most mild, digestible and 
unstimulating character, with very little, if any, animal food. The 
drinks too should be cool, and in no case of a stimulating character. 
To allay irritation and constringe the enlarged capillaries of the inflamed 
mucous membrane, a pill composed of the sulphate of iron and extract 
of conium, of each one grain, may be given after eating three times per 
day. Cups or blisters should be applied over the stomach, or what in 
many cases may do better, pustulation may be produced by tartar emetic 
ointment. 

In cases of dyspepsia attended with acidity and looseness of the bowels, 
a little lime water or prepared chalk may be taken each morning for a 
time ; if there be acidity, with constipation, a teaspoonful of magnesia 
may be given instead ; but if there be constipation without acidity, a pill 
of aloes and rhubarb may be given after dinner each day. 

SECTION XXI.— DIARRHOEA. 

By diarrhoea, from 8ta, "through," and ps«, "to flow," I mean an affec- 
tion of the intestines or alimentary canal, attended with frequent, and 
generally more or less copious liquid olvine evacuations of a feculent 
character. 

The immediate condition upon which diarrhoea depends is generally 
either relaxation, congestion, irritation or inflammation of the alimentary 
25 



386 DISEASES OF THE DIGESTIVE SYSTEM. 

mucous membrane ; in consequence of which there is poured into the 
alimentary canal a serous mucus or other fluid, which, mixing with the 
fecal matter produces the liquid evacuations in their various forms. 

Symptoms. — In cases of diarrhoea depending upon a relaxed condition 
of the alimentary mucous membrane, the discharges are generally quite 
frequent though attended with little or no pain; there is apt to be emacia- 
tion, and if the disease be protracted, the discharges may become very 
copious and the prostration very great. 

In diarrhoea from congestion of the alimentary mucous membrane, 
there is apt to be a feeling of fullness in the abdomen, especially before 
an evacuation, and sometimes more or less pain, and the evacuations are 
apt to be copious and may occur with more or less distressing vomiting. 

Diarrhoea depending upon irritation of the mucous and muscular coats 
of the intestines, is attended with more or less pain and an increased 
peristaltic action of the intestines, the discharges, in many cases, being 
small but very frequent. The discharges may be attended with slight 
sinking, but more or less febrile excitement is liable to attend this variety 
of the disease. 

In cases of diarrhoea depending upon inflammation of the alimentary 
mucous membrane, with irritation of the muscular coat, there is tender- 
ness, pain and increased peristaltic action of the intestines, with frequent 
discharges, though in many cases not very copious. The pain and tenes- 
mus are often very considerable, and there is apt to be more or less fever, 
with thirst, a dry, hot skin, &c. 

Thus we have the symptoms common to diarrhoea from relaxation, 
congestion, irritation, and inflammation of the alimentary mucous mem- 
brane. There may be, however, an obstinate diarrhoea depending upon 
hepatic derangement, or upon ulceration, or some other organic disease 
of the alimentary canal. In such cases, the symptoms vary according 
to the seat and nature of the disease upon which the diarrhoea depends. 

If the liver be the cause, there is apt to be a jaundiced appearance. 
If ulceration or other organic disease of the intestines be the cause, there 
is liable to be pain, tenderness, emaciation, debility, and finally death, 
unless the disease be arrested. 

Causes. — The causes of diarrhoea are exceedingly numerous, and con- 
sist of those that operate directly upon the alimentary mucous membrane, 
and those which operate through the system, in various ways. 

All the causes which lead to indigestion, such as indigestible or un- 
wholesome food, irregular eating, the use of intoxicating liquors, &c, may, 
by producing dyspepsia, lead to diarrhoea. The causes operating directly 
in this way, generally produce more or less irritation or inflammation 
of the alimentary mucous membrane, but if the causes have operated for 
a long time, they are not only direct, but indirect agents, in producing 
this disease ; and may produce diarrhoea from the debility or relaxation 
which they have caused. 

Of the indirect agents, any cause capable of producing a general 
relaxed, congested, irritated, or inflamed condition of the alimentary 
mucous membrane, may produce a diarrhoea : among which are great 
fatigue, want of proper nourishment, the use of tobacco, intoxicating 
liquors, and various other abuses of the system, all of which, by pro- 



DIARRHCEA. 387 

ducing debility of the system, and relaxation of the alimentary mucous 
membrane, may become the cause of diarrhoea. 

Cold is a very prominent cause of diarrhoea, as it checks the exhala- 
tion from the skin, and thus retains in the blood an irritating fluid, 
■which, passing to the alimentary mucous membrane, produces congestion, 
irritation, and perhaps inflammation, and so a diarrhoea. 

Congestion of the liver, from various causes, by interrupting the por- 
tal circulation, increases the congestion of the alimentary mucous mem- 
brane, and so becomes a cause of diarrhoea. There are many other 
causes of diarrhoea, or conditions of the system in which a diarrhoea 
occurs, it being sometimes colliquative, and at others critical, indicating 
a favorable change in the primary febrile or other affection. 

Prognosis. — In cases of diarrhoea, not depending upon great debility, 
or inflammation, ulceration, or some other organic disease, the prognosis 
is generally quite favorable, and the disease may be expected to yield in 
a reasonable time, to proper remedial measures. 

In cases, however, in which there is great debility, and causes ope- 
rating of a serious character, which cannot be removed, the diarrhoea 
may pass on for weeks, months, or even years, in spite of remedial 
measures. 

Treatment. — In the treatment of diarrhoea the cause should be sought 
out and removed, the patient should be placed on a properly regulated 
diet, and then just so much direct medical treatment should be resorted 
to as is absolutely necessary, and no more. If the diarrhoea depends 
upon indigestion, the dyspepsia should be corrected by such measures as 
may be indicated, when the diarrhoea will generally subside. 

If it arise from exposure to cold, by which the exhalation from the 
skin is checked, the patient should be warmly clad with flannel next the 
skin, be directed to sleep in flannel sheets, and to take an unstimulating 
and digestible diet. If this fails to correct the disease, five grains of 
Dover's powder may be given, every six hours, till the diarrhoea is 
arrested. 

In cases of diarrhoea depending upon hepatic congestion, and conse- 
quent congestion of the portal vessels, a blue pill may be given morning 
and evening, till the hepatic derangement is corrected, when the diarrhoea 
will generally subside, or may be corrected by very mild anodynes or 
astringents, such as three grains of Dover's powder, with two of tannin, 
taken four times per day. 

In diarrhoea depending upon great debility of the system, and relaxa- 
tion of the alimentary mucous membrane, the tincture of the chloride of 
iron, in ten drop doses, three times per day, is a valuable remedy for the 
local affection, and also for the general strength of the patient. Or, in 
case this should disagree, the elixir of vitriol may be given, in twenty 
drop doses, in two fluid ounces of water, four times per day, instead of 
the iron. 

In cases of diarrhoea depending upon congestion of 'the alimentary 
mucous membrane, the warm foot-bath, sinapisms over the abdomen, 
warm clothing, and a properly regulated diet will do very much towards 
arresting the disease. If, however, the diarrhoea continues, the fluid ex- 
tract of blackberry, in drachm doses, may be given three times per day, 
to constringe the alimentary mucous membrane. 



388 DISEASES OF THE DIGESTIVE SYSTEM. 

In cases of diarrhoea depending upon irritation of the alimentary 
mucous membrane, twenty drops of the elixir of vitriol, with ten drops 
of laudanum, may be given four times per day, in a little water, and 
continued with sinapisms, warm clothing, and proper food, till the 
diarrhoea is corrected. Finally, in all cases of diarrhoea depending upon 
inflammation of the alimentary mucous membrane, cups, blisters, or pus- 
tulation with tartar emetic ointment should be resorted to; the patient 
should be properly fed and clothed, and if this fail to effect a cure, three 
grains of Dover's powder, with two of tannin may be given, four times 
per day, till the disease be arrested. 

SECTION XXII.— CHOLERA MORBUS. 

By cholera morbus, or sporadic cholera, I mean that peculiar affection 
of the alimentary canal, characterized by vomiting and purging, and 
attended frequently with more or less cramps or spasms of the abdo- 
minal muscles, and also of the extremities, and in severe cases, with con- 
siderable prostration. 

Symptoms. — Cholera morbus generally makes its attack suddenly, and 
is very apt, in our climate, to come on during the cool hours of the night, 
at the season of the year when the days are warm and the nights cool. 
The attack is sometimes preceded, for a day or two, by a feeling of indis- 
position, with impaired appetite, headache, &c. But as often, no premo- 
nitory symptoms are noticed, the attack being sudden and unexpected. 

The disease commences with a feeling of oppression in the stomach 
and bowels, with perhaps chilliness, and a feeling of great distension, 
with violent pain in the umbilical region. Soon there is nausea and 
griping pains, with obstinate vomiting and copious liquid discharges from 
the bowels. 

The matter discharged by vomiting, and by stool, consists, at first, of 
the contents of the stomach and intestines, with a serous fluid. In some 
cases, however, the discharges are mingled with bile, especially the 
matter vomited. The pulse becomes weak and frequent, the skin cool 
and moist, the strength is prostrated, and along with cramps, there is 
apt to be prostration, and there is sometimes wandering of the mind, or 
slight delirium. 

If the discharges continue, they may lead on to a fatal termination. 
Or reaction may take place, followed by febrile action, with a hot and 
dry skin ; and all the symptoms which usually attend gastro-enteritis. 
The discharges may become scanty; the epigastrium tender; the abdomen 
distended, and the fever, unless the disease be arrested, is apt to assume 
a typhous character, and the patient, with great prostration, and mutter- 
ing delirium, passes on to dissolution, or to a slow and tedious convales- 
cence. 

Causes. — Atmospheric vicissitudes, or sudden checking of the cutaneous 
exhalation, by cool night air, is probably the most frequent cause of this 
disease. This sudden retention of the perspirable matter, renders the 
blood more dilute or watery, and ready to part with its serum ; and also 
accounts for the chilliness, prostration, and congestion, which occurs by 
its debilitating effects upon the brain and nervous system. 

The paludal poison also, by acting upon the brain and nervous system, 



CHOLERA MORBUS. 389 

through the blood, is a frequent cause of cholera morbus ; producing its 
effects probably in nearly the same manner, as retained perspirable mat- 
ter, especially at seasons of the year favorable to the occurrence of this 
disease. Besides cold and the paludal poison, which may act as predis- 
posing, or exciting causes of cholera morbus, there are various other 
exciting causes ; among the most frequent of which, are violent fits of 
anger, or strong mental emotions, sailing upon a rough sea; the drinking 
of too much cold water in hot weather, and finally, the eating of green 
vegetables, such as cucumbers, melons, unripe fruits, &c. 

Diagnosis. — Little difficulty need be experienced in distinguishing a 
case of sporadic cholera, or cholera morbus, from malignant cholera ; or 
in fact from any other disease. It is only necessary to take into account 
the season of the year, the epidemic tendency, the mode of attack, the 
character of the discharges, and all the peculiar symptoms of this disease, 
and the diagnosis may be clear in all cases. 

Nature. — When we remember that retained perspirable matter, and 
the paludal poison, together with the eating of crude green vegetables, 
are the most frequent causes of cholera morbus; there need, I believe, 
be little doubt, in relation to the pathology of the disease. 

The retained perspirable matter, as well as the marsh miasmata, evident- 
ly directly prostrate the cerebro-spinal system, and both directly, and 
through this general prostration, produce congestion of the liver, of the 
portal vessels, and of the alimentary mucous membrane. If now green 
vegetables have been taken, to disturb still further, the alimentary mucous 
membrane ; we have not only congestion of the liver, and portal vessels ; 
but also congestion, with irritation of the alimentary mucous membrane. 

Now, in this state of the system, the blood readily parts with its serum, 
which in the congested state of the alimentary mucous membrane, is 
poured into the stomach and intestines, and mixing with the fecal matter, 
is thrown off by vomiting and purging. In cases in which green vegeta- 
bles have been taken, in addition, there is apt to be a strong tendency to 
gastro-enteritis, as the vomiting and purging subside, probably from the 
gastro-intestinal irritation which they produce. 

Treatment. — The indications in the treatment of cholera morbus, are 
plainly to equalize the circulation, to remove any offending matters from 
the alimentary canal, to counteract gastro-intestinal irritation, and to 
arrest the vomiting and purging as well as to correct the hepatic and 
other functions of the body. 

If the patient is chilly and prostrated, the whole length of the back 
should be rubbed with a warm decoction of capsicum in vinegar, to 
equalize the circulation and produce warmth. A large sinapism should 
be applied all over the stomach and bowels, and allowed to irritate a 
little short of vesication. And it should be reapplied every six or eight 
hours while the disease continues. 

To stop the vomiting, one-fourth of a grain of calomel, with a grain 
of Dover's powder may be given every fifteen minutes, till it be arrested 
after which, if there is evidence of irritating matters in the alimentary 
canal, a full dose of calomel may be given, and followed if necessary in 
five hours, with half an ounce of castor oil. In cases, however, in which 
no offending matter is suspected in the intestines, a cathartic need not 



390 DISEASES OF THE DIGESTIVE SYSTEM. 

be given, but after arresting the vomiting, if the diarrhoea continues, 
five grains of Dover's powder, with one or two grains of calomel may be 
given every four or six hours, till the hepatic function is restored and 
the bowels corrected, 

Or, if the calomel is not indicated, there being only a looseness of the 
bowels, with increased peristaltic action instead of the calomel and 
Dover's powder, fifteen drops of laudanum, with a grain of camphor may 
be given, the camphor and laudanum being suspended in water by means 
of a little prepared chalk. While the nausea continues, chicken tea, or 
crust coffee, with a little milk may be allowed ; but later, a poached egg, 
toast, and other plain and digestible varieties of nourishment may be 
allowed. In case gastro-enteritis follows an attack of cholera morbus, 
blisters and other measures proper in the treatment of mucous gastro- 
enteritis should be persevered in till the inflammation is overcome. 

SECTION XXIII.— MALIGNANT CHOLERA. 

By malignant cholera, I mean that peculiar epidemic malignant variety 
of disease characterized by vomiting and purging, and attended with 
cramps, or spasmodic contractions of the abdominal muscles, and some- 
times of the extremities, and in severe cases with great prostration and 
a state of collapse. 

Malignant cholera appears to have been long known in the east, but 
it did not attract the attention of the medical profession to any con- 
siderable extent, till it appeared in Hindostan, in 1817, from whence it 
spread over Asia, and subsequently over Europe and America, and in 
fact, almost every part of the globe. 

It appears to have been truly "the pestilence that stalks abroad at 
noon-day," sweeping off, in its onward march, that portion of the human 
family fitted for destruction, generally by a reckless disregard of the 
laws of health; and taking, occasionally, an unfortunate victim whose 
greatest misfortune consisted in being surrounded by the filthy, reckless 
and debased. 

Symptoms. — Malignant cholera may be preceded by a slight diarrhoea, 
for a time, but it more frequently comes on suddenly, with a sense of 
tension in the epigastrium, and cramps of the stomach and intestines, 
with exceedingly distressing nausea. Very soon severe and obstinate 
vomiting and purging commence and continue, with but very short 
intervals, till the system is exhausted or a collapse occurs unless the dis- 
ease be arrested. During the intervals between the attacks of vomiting, 
the patient is harassed with continual nausea, and a feeling of great 
distress in the epigastrium. 

The patient is usually cold or more or less chilly at the commence- 
ment of the disease, and in some instances this coldness continues and 
becomes so considerable that I have found even the tongue feeling cold 
to the touch. In these cold cases the face and whole surface of the body 
has a shrunken, livid, or blue appearance, and the cramps are often very 
severe. No bile is thrown from the stomach or passed by the bowels, 
and after the first two or three discharges, no fecal matter ; the matter 
vomited and discharged by the bowels being liquid and of a rice-water 
appearance. 



MALIGNANT CHOLERA. 391 

Sometimes very early in this disease, and at other times later, the dis- 
charges become less frequent and copious, and collapse supervenes, 
attended with great prostration and apparent insensibility; the evacua- 
tions being unheeded by the patient, and little or no regard paid to sur- 
rounding objects. The pulse becomes weak and scarcely perceptible, 
the skin cold, livid, and covered with a clammy sweat; there is great 
thirst ; the voice fails ; the countenance is cadaverous, the face being 
shrunken, and the eyes hollow; respiration is slow, and in some cases 
the patient is only aroused from apparent insensibility by the cramps 
which occur, affecting mainly the bowels, abdominal muscles and the 
inferior extremities. 

Malignant cholera is thus one of the most rapidly fatal diseases, death 
being liable to take place at any period, from five or six hours, to one, 
two, or three days from the time of attack. If a collapse occurs, the 
case is always attended with the greatest danger, but if the discharges 
become less copious, and assume a bilious or feculent character, the case 
will generally terminate favorably. The convalescence may be rapid in 
some cases which are arrested early, but in obstinate protracted cases, as 
the vomiting and purging cease, the skin may become hot and dry, the 
tongue clean and red ; delirium may occur ; and there may be a general 
irritated febrile reaction, with symptoms of gastro-enteritis, the fever 
assuming a typhoid character. Thus, then, we have in malignant cholera, 
in some cases, a premonitory stage, during which there may be languor, 
nausea, and diarrhoea. There is also the active stage of the disease, 
attended with nausea, vomiting, purging, cramps, &c. There may be 
also the stage of collapse, marked by extreme prostration, coldness, 
thirst, clammy sweats, and partial or entire insensibility to surrounding 
objects. And, finally, there is the stage of convalescence which may be 
rapid, or it may be tedious, developing at first, an irritative febrile 
reaction, with symptoms of gastro-enteritis, the fever having a typhoid 
tendency. 

Such then are the general symptoms of malignant cholera, but it must 
be remembered that the symptoms vary widely in different cases, all, 
however, exhibiting more or less malignity. 

Anatomical Characters, — In cases in which death takes place very 
early, no marked morbid changes may be discovered on examination of 
the body. In cases, however, in which death has taken place during a 
state of collapse, the arteries contain but little blood, but the veins and 
right side of the heart are gorged with dark blood, imperfectly coagu- 
lated, and nearly all parts of the body exhibit more or less signs of 
venous congestion. 

The lungs, however, contain little blood, the spleen is contracted, the 
peritoneum and other serous membranes are dry, the small intestines are 
injected and of a rese color, the mucous membrane may appear nearly 
natural, or it may be reddened, with enlargement of the intestinal folli- 
cles, and there may be small semi-transparent vesicles along the mucous 
membrane of the small intestines. The alimentary mucous membrane is 
sometimes found coated with a whitish matter identical with that con- 
tained in the evacuations, and the intestines are found distended with the 
same rice colored liquid of which the discharges consist, mixed, in some 



392 DISEASES OF THE DIGESTIVE SYSTEM. 

cases, with effused blood. A glairy mucus is sometimes found adhering 
to the mucous membrane of the stomach, but this tissue may retain 
nearly a natural appearance. It appears from microscopic examinations, 
that the whitish matter adhering to the alimentary mucous membrane 
consists of the epithelium partially detached from the basement mem- 
brane, and that the white deposit in the evacuations consists of "disinte- 
grated epithelium of the alimentary mucous membrane."* 

In cases in which death has taken place after reaction, the venous in- 
jection is scarcely, if at all apparent, the blood is less dark and viscid, and 
the contents of the intestines instead of presenting the rice water appear- 
ance, is of a more or less bilious or bloody appearance. The alimentary 
mucous membrane presents signs of inflammation, being red, and some- 
times softened, the mucous follicles presenting signs of incipient ulcera- 
tion. 

Such are the ordinary post-mortem appearances presented in subjects 
dead of this most malignant disease, the differences depending upon the 
time at which death occurs, as well as the condition of collapse or 
reaction. 

Diagnosis. — To distinguish malignant from sporadic cholera, it is only 
necessary to take into account the epidemic influence, the rice-water 
discharges, the shrinking, coldness, and blueness of the extremities, and 
surface of the body, the great violence of the spasms, together with the 
rapid sinking tendency, and the collapse when it occurs, to render the 
diagnosis clear. 

Causes. — The predisposition to cholera arises, I am satisfied, from the 
various imprudences to which the human family are addicted ; the most 
prominent of which are irregularity in eating, taking improper or un- 
wholesome food, the use of tobacco and intoxicating liquors, masturba- 
tion and excessive venery, filthy habits of every kind, mental despon- 
dency, low and vicious habits of life, damp and filthy apartments, and 
finally, every deviation from the laws of health to which depraved mortals 
are addicted. 

It is probable that all these imprudences with others of a kindred 
character, not only impair vitality and thus predispose those guilty of 
them to malignant cholera, but it is probable that the sum total of human 
imprudences, produces or causes to be generated the epidemic influence, 
whether it be animal, vegetable or inorganic, which is the general ex- 
citing cause of this disease. 

Now with the predisposition and a general exciting cause thus pro- 
duced, it is easy to see that a damp atmosphere with a low electrical 
state, together with various imprudences in eating and drinking, may act 
also as occasional exciting causes of malignant cholera, as is well 
known to be the fact. But in relation to the natural agents, such as 
electricity, planitary influences, &c, they cannot probably be operative 
in producing this or any other disease only in so far as the human sys- 
tem is depraved, or has been let down from its original state of physical 
perfection, by imprudences which have been operating since the fall of 
man. 

Nature. — In order to appreciate the nature of malignant cholera, it is 

* See Wood's Practice of Medicine, Vol. i, p. 722. 



MALIGNANT CHOLERA. 393 

necessary to remember that it generally occurs in persons predisposed by 
imprudence of some kind, and that a poison epidemic influence of either 
an organic or inorganic nature, is received into the system through the 
skin, stomach or lungs, which acts as the exciting cause of the disease. 
It is probable that this poisonous agent passes with the blood to every part 
of the system, producing a direct depressing effect upon the cerebro-spinal 
and ganglionic systems, thus deranging the functions of all the organs 
of the body. 

It is possible also that this poison produces a direct change in the 
blood, in consequence of which it more readily parts with its serum, and 
it may possibly irritate directly the alimentary mucous membrane ; be 
this as it may, there is very soon cerebro-spinal congestion, as well as 
congestion of the alimentary mucous membrane. Now the cerebro- 
spinal congestion with that of the alimentary mucous membrane, together 
with the state of the blood, account for the coldness, nausea, vomiting, 
purging, cramps, and other symptoms which are developed. 

The collapse may occur from the combined influence of the poison, 
the loss of the serum of the blood, and from the degranement in the 
pulmonary circulation, preventing a due decarbonization of the blood. 
In cases in which there is an irritated reaction, with a fever of a typhoid 
character, following a collapse, there is evidently a gastro-enteritis which 
accounts for the symptoms which are developed, which gastro-enteritis 
may be the result of the disease, or of the remedies which have been 
resorted to for its cure. 

Prognosis. — Malignant cholera is always a dangerous disease. But 
if the case receive early and proper attention, and the predisposition is 
not strong, or the surroundings unfavorable, a recovery may reasonably 
be expected. If, however, the patient is strongly predisposed, if the 
case be neglected or imprudently managed, or if collapse has supervened, 
with coldness, lividity, &c, a fatal termination may be apprehended. The 
ratio of deaths in some localities has been one-half, or even more than 
that; but, judging from my own observation, I should think that of all 
the cases of malignant cholera which occur, a large majority recover ; 
but in some localities and epidemics it may be otherwise. 

Treatment. — The indications in the treatment of malignant cholera 
are to equalize the circulation, to arrest the vomiting and purging, to 
counteract local irritation, and to restore the functions of the liver, ali- 
mentary canal, and other organs. 

If a case of cholera be seen early, it may sometimes be arrested by 
very mild measures. The patient should have the feet placed in warm 
water, and active friction should be made along the spine, with a strong 
decoction of capsicum in vinegar, used a little warm, with a flannel cloth. 
A mustard poultice should be applied, large enough to cover the epigas- 
trium and whole abdomen, and allowed to irritate a little short of vesi- 
cation. Ten drops of laudanum, with the same quantity of the tincture of 
camphor, may be administered every four hours, with a teaspoonful each 
of brandy and loaf sugar, and the patient may be allowed to drink warm 
crust coffee, one-third milk, or chicken tea. 

The warm foot-bath favors the circulation in the extremities, the warm 
friction along the spine equalizes the circulation, the sinapisms counter- 



394 DISEASES OF THE DIGESTIVE SYSTEM. 

act the local irritation and congestion of the alimentary mucous mem- 
brane, while the small doses of laudanum and camphor, with the brandy 
and sugar, tend to allay the nausea, arrest the purging, and to quiet 
general restlessness and irritability. With this plain and simple course 
of treatment, many cases of malignant cholera may be arrested, if early 
and judiciously applied. 

In case, however, the vomiting continues obstinate, the laudanum, 
camphor and brandy being rejected, this prescription may be discon- 
tinued, and a grain of Dover's powder, with one-fourth of a grain of calo- 
mel, may be given every half hour, till with the other measures the 
vomiting is arrested. After the vomiting is arrested, or as soon as the 
stomach will retain it, four grains of Dover's powder, with two grains 
each of calomel and pulverized camphor may be given every four hours, 
with a little prepared chalk, and continued till the discharges become 
bilious, when the calomel should be discontinued, and two grains of tan- 
nin given with the Dover's and camphor, instead, and continued till the 
disease is arrested. 

In case the rice-water discharges continue obstinate, fifteen or twenty 
drops of laudanum may be given by injection, with half an ounce of 
liquid starch, and repeated at intervals of four hours, alternating with 
the powders, if they appear to produce relief. Should the disease con- 
tinue in spite of the remedies I have suggested, and great prostration, 
with collapse supervene, from two to four grains of the sulphate of qui- 
nine may be given every four hours, with, or alternating with, the Do- 
ver's, tannin and camphor, and continued till death or reaction takes 
place. Finally, should reaction take place, and symptoms of gastro- 
enteritis supervene, with an irritated febrile reaction, the fever assuming 
a typhoid character, the quinine and camphor may be continued, with 
or without the Dover's, and a blister applied to the epigastrium, and if 
necessary to the abdomen, and thus the gastro-enteritis subdued, and 
the typhoid tendency counteracted, till convalescence is fully estab- 
lished. 

During the continuance of the disease, the patient should be nourished 
by crust coffee, one-third, or one half milk, or chicken tea, or mutton 
broth may be allowed; and if necessary, wine-whey may be resorted to, 
in case of great prostration or collapse. During convalescence, a plain 
digestible, and nourishing diet may be allowed, consisting in part of 
animal food, to be taken with strict regularity. And should the appetite 
be indifferent, twenty drops of the fluid extract of columbo, or small 
doses of the cold infusion may be given, after each meal for a time, till 
the tone of the stomach is restored. 



SECTION XXIV.— CHOLERA INFANTUM. 

By cholera infantum, I mean that peculiar disease of infants, and very 
young children, occurring during the warm season, and more especially 
in cities and large towns, characterized by vomiting, purging, and great 
emaciation, and sometimes assuming a rapidly fatal character. 

Symptoms. — Cholera infantum may come on suddenly, with scarcely 
no premonitory symptoms, or it may commence in a slow and insidious 






CHOLERA INFANTUM. 395 

manner, with occasional vomiting; a little diarrhoea, and perhaps symp- 
toms of slight congestion, or inflammation of the alimentary mucous 
membrane. The brain appears to suffer materially in some cases; being 
either congested, irritated, or inflamed, either in its substance, or its 
meninges. The liver appears to be deranged in the early stages of this 
disease, as very little, or no bile is visible in the evacuations, the dischar- 
ges consisting generally of a colorless liquid. Later, however, the 
discharges may assume a yellow, brown, or green appearance. 

In acute cases, in which no premonitory symptoms are apparent, the 
disease commences with vomiting and purging; the extremities become 
cold; the respiration difficult; the face pale, and the eyes sunken; the 
pulse almost imperceptible ; the vomiting and purging are almost inces- 
sant, and the little sufferer exhibits symptoms of spasmodic pains in the 
stomach and bowels, and unless the disease be arrested, great prostration 
ensues, with pale and shrunken features, coma, insensibility, and finally 
death takes place, at a period varying from six to twenty-four hours from 
the attack. 

In other cases, however, the disease comes on more slowly ; the child 
suffering for a few days, with occasional vomiting, and slight diarrhoea, 
and perhaps with an irregular fever, apparent headache, &c. After 
these symptoms have continued for a time, active vomiting and purging 
is apt to occur during the night, with most of the symptoms of an acute 
attack of the disease. 

Along with the vomiting and purging, in such cases, the extremities 
become cold ; the pulse small and frequent ; the tongue is furred, and if 
the vomiting, and excessive purging be arrested, there is often a diarrhoea 
remaining; which may continue on for several days, weeks, or even 
months, unless arrested. In such cases, the child suffers from an irregu- 
lar fever; the flesh becomes soft; emaciation goes on rapidly; the face 
becomes pale, and the eyes sunken ; the abdomem becomes either disten- 
ded or sunken ; the mouth becomes apthous ; the child becomes restless, 
and moans almost incessantly ; and unless the disease be arrested, the 
little sufferer may die, either in a comatose state, or else in violent con- 
vulsions. 

The duration of this disease in its acute form as we have seen, may 
vary from six to twenty-four hours, but a diarrhoea with all the usual 
symptoms of gastro-enteritis may continue on for days or even weeks, 
unless arrested by proper remedial measures, or terminated by the return 
of cool weather, or some other favorable circumstance. 

Anatomical Characters. — In cases in which death occurs early, the 
liver is found congested, and the mucous membrane of the alimentary 
canal is either congested, as is found in some cases, or else it presents 
unusual paleness with little or no congestion. 

In cases in which death has occurred at a later stage, signs of inflam- 
mation are presented by the alimentary mucous membrane. And in 
chronic cases, the mucous follicles are enlarged, and ulcerated not only 
in the small, but in the large intestines. The brain is sometimes found 
congested with serous effusion into its ventricles, and in some chronic 
cases that have exhibited symptoms of hydrocephalus, the brain is found 
more or less softened. 



396 DISEASES OF THE DIGESTIVE SYSTEM. 

Causes. — As cholera infantum occurs most frequently at the season of 
the year when the days are warm and the nights cool ; it appears pro- 
bable that cold, following moderate heat is one of the most frequent 
causes of this affection. This is not strange when we remember how. 
sensitive the infant is, to any impressions of an exciting irritating or 
depressing character. The sudden check to the perspiration during the 
night, produces congestion of the cerebro-spinal system, of the liver, and 
of the alimentary mucous membrane, and hence, if the child be predis- 
posed from impure city air, or from any other cause, a rapid and, per- 
haps fatal attack of the disease is produced. Cases occurring from this 
cause are generally rapid in their course, and may terminate in death 
or convalescence within a few hours. 

While cold is the most frequent exciting cause of the acute form of 
this disease, there are various causes which operate either directly or 
indirectly in producing the more chronic form of this affection, among 
the most frequent of which are impure city air, damp and filthy sleep- 
ing rooms, dentition, improper food, or irregularity in taking it, and 
Jcoiho or idio miasmata. Any or all these causes may predispose the 
infant or child to this affection, or they may not only predispose, but 
act as exciting causes, developing generally the chronic form of the dis- 
ease, with cephalic, hepatic, or severe gastro-intestinal complications. 

Nature. — In the acute form of the disease, there is evidently depressed 
vitality from some predisposing cause, and a weak state of the blood. 
This condition, together with the effects of retained perspirable matter, 
miasmata, or some other depressing agent, leads to congestion of the 
cerebro-spinal system, liver, portal vessels, and alimentary mucous mem- 
brane, and hence the vomiting, purging, and other symptoms which are 
developed in this disease. But in chronic cases which are preceded and 
followed by diarrhoea, there is evidently in addition to the congestions ; 
irritation or inflammation of the alimentary mucous membrane, affecting 
especially the mucous follicles; the cephalic, and other complications 
being probably accidental in most cases at least. 

Treatment. — The predisposing and exciting cause or causes of this 
affection, should be sought out and removed as far as possible, and the 
case treated according to the condition of the patient at the time of 
attack. In those cases which occur from a sudden check of the perspi- 
ration, from cold, the feet should be placed in warm water, and the back 
of the child rubbed with a warm flannel, to help equalize the circulation. 
Mustard moistened Avith vinegar and spread on a thin cloth, the cloth 
being folded over it, should be applied over the stomach and bowels, and 
also to the bottom of the feet, and kept on as long as the child can bear 
it without producing vesication. 

To allay the vomiting in such cases, ten drops of paregoric may be 
given, with a grain of prepared chalk, every three or four hours, the 
child being allowed a little chicken tea, if it can be retained by the sto- 
mach. If, however, the case continues obstinate, and the discharges 
contain no bile, the paregoric should be suspended, and half a grain of 
Dover's powder, with a grain of calomel, given every three hours, till 
the discharges assume a bilious character, when the calomel should be 
omitted, and the Dover's powder continued, with one sixth of a grain 



FLATULENT COLIC. 397 

each of camphor and tannin, every four hours, till the discharges are 
arrested, when they should be gradually left off, and the child fed on 
chicken tea or arrow-root, cooked in milk or chicken broth. 

The child should be dressed in flannel, and should lay in flannel 
sheets, and should the case become chronic, and symptoms of gastro- 
enteritis supervene, a blister may be applied to the epigastrium, and 
also to the abdomen, if necessary, and thus this complication be subdued. 
In those cases which appear to be of a malarious origin, a small dose of 
calomel, or mercury with chalk, may be given with a little rhubarb and 
castor oil, and then the case treated in every respect according to the 
principles already laid down, adding the sulphate of quinine to the treat- 
ment in all cases in which it is clearly indicated. 

In those cases depending upon unwholesome food, and damp impure 
air, the diet should be corrected ; the child, if possible, removed to more 
suitable quarters, a flannel should be made to fit snugly to the whole 
body, and the feet and legs should be protected by woollen stockings, 
to keep the surface warm and promote perspiration. Dover's powder, 
with the sulphate of quinine, in half grain doses each, may be given with 
a little prepared chalk at first, and later, if a diarrhoea follow, the child 
may be fed on milk and water with a little arrow-root, in which has been 
boiled the root of the geranium maculatum, so as to render it conside- 
rably astringent. 

In those cases in which there is much irritation from dentition the 
gums should be cut, and if the brain or its membranes are irritated or 
inflamed, small blisters may be applied back of the ears. 

To prevent this disease, and to aid in its cure when it has occurred, 
all children should be kept clean, dry, and warm, and allowed good pure 
dry air, and proper wholesome food, which should be taken with regu- 
larity. For infants, the mother's milk is the most natural and proper 
food, and it should be allowed in all cases in which it is possible to do 
so. But in case this cannot be had, or that of a healthy wet nurse, fresh 
cow's milk, diluted with water, may be substituted. For older children, 
arrow-root cooked in chicken broth, or milk and water, will generally be 
found the most suitable food in this variety of disease. 

SECTION XXV.— FLATULENT COLIC. 

By flatulent colic, I mean that variety arising from an accumulation 
of air in the alimentary canal, characterized by pain in the bowels, of a 
paroxysmal character, to some extent, and unattended with inflammation. 
This variety of colic is apt to attack persons of weak stomachs, or those 
whose intestines, or their muscular coat, is in a weak and debilitated or 
relaxed state. Various articles of food are liable to provoke an attack 
of flatulent colic in those who are predisposed, among the most frequent 
of which are cucumbers, unripe fruit, fresh, warm bread, &c. In some 
cases, the colic pains are felt in about an hour after taking food, but 
frequently the food passes into the intestines, before the disease is de- 
veloped. 

Symptoms. — The patient usually experiences a sense of distension and 
uneasiness in the pit of the stomach, which is soon followed by a dis- 



398 DISEASES OF THE DIGESTIVE SYSTEM. 

tressing pain in the abdomen, referred in most cases to the umbilical 
region. The pain may extend to the whole abdomen, and become very 
severe, with only slight remissions, but more frequenly it occurs in severe 
paroxysms, with more or less complete intervals of quiet from the pain. 

During the exacerbations the patient is apt to move to and fro, with 
the body bent forwards, and the hands pressed firmly against the abdo- 
men. In cases in which the stomach is the seat of the suffering, if 
eructations of wind occur, there is apt to be some mitigation of the 
pain. If, however, the colon be the seat of the difficulty, the wind is 
apt to pass downwards, as the disease is about terminating. 

In some cases of flatulent colic, the abdominal muscles are contracted, 
while in other cases, considerable tympanitis attends. The bowels are 
generally constipated, the pulse natural, or slightly depressed, and the 
tongue may be clean, or covered with a white fur. 

Diagnosis. — -Flatulent colic may be distinguished from bilious colic, 
by the absence of bilious symptoms, especially the bilious vomiting, so 
generally attending bilious colic. Flatulent colic may be distinguished 
from peritonitis and gastro-intestinal inflammation, by the absence of 
fever, by the pain being irregular, and generally relieved by pressure, 
and by the motions of the patient. Finally, this affection may be dis- 
tinguished from strangulated hernia, by a careful examination of the 
abdomen, in connection with the other symptoms which are developed. 

Prognosis. — The prognosis in flatulent colic is generally favorable, 
but in obstinate and protracted cases, the muscular coat of the intestines 
becomes so far paralyzed, as to produce in some cases very troublesome 
constipation of the bowels. 

Treatment. — The treatment of this disease consists in the use of means 
to correct the attack of colic when it occurs, and also to correct the con- 
dition and habits of the patient, upon which the colic depends. In a 
mild attack of colic, gentle friction along the spine with a warm flannel, 
sinapisms over the stomach and bowels, and a teaspoonful of the 
tincture of camphor, administered in water, will generally arrest the 
disease. 

In those cases which come on soon after eating some crude indigesti- 
ble food, an emetic of ipecac may be indicated. Thirty grains may be 
dissolved in two ounces of warm water, and half an ounce given every 
fifteen minutes, till free vomiting is produced. Or what may be more 
convenient, if at hand, a drachm of the fluid extract may be added to 
two ounces of warm water, and a tablespoonful given every fifteen 
minutes till vomiting is produced. 

After free vomiting, thirty drops of laudanum, or the same quantity 
of the fluid extract of opium, may be administered, with sixty drops of 
the tincture of camphor, and repeated in two hours, if necessary. The 
friction along the spine, and sinapisms over the bowels, should be used 
in these, and all other cases of flatulent colic ; and if there be any 
tender point along the spine, dry cups may be applied, and cupping may 
even prove servicable in cases in which there is no apparent spinal ten- 
derness. 

In flatulent colic attended with obstinate constipation, after resorting 
to the remedies I have suggested, a cathartic may be indicated. Half 



BILIOUS COLIC. 399 

an ounce of castor oil may be given, "with a teaspoonful of the oil of tur- 
pentine, and the dose repeated in four or six hours, if necessary. In 
this way an attack of flatulent colic may generally be arrested ; but it 
is desirable to correct the habits and condition of the patient, upon 
■which the attacks of colic depend. If the digestion is bad the diet 
should be regulated, and the patient directed to take proper food, with 
regularity, and made to conform rigidly to the laws of health, in every 
respect. 

If the bowels are constipated, and they cannot be corrected by a tea- 
spoonful of calcined magnesia, taken every morning, or by a pill of 
aloes and rhubarb, taken after dinner, each day, a degree of paralysis 
of the muscular coat of the alimentary canal may be suspected. In 
such cases, strychnia may be administered, in gV of a grain doses, three 
times per day, for a time, with the most happy effect, if there be no 
marked irritation of the brain or spinal cord. A grain of strychnia may 
be rubbed in a mortar with a teaspoonful each of acetic acid and sugar, 
and then eight ounces of water added ; or if the muriate of strychnia be 
at hand, a grain of it may be dissolved in half a pint of water, and of 
either preparation a teaspoonful may be given, three times per day, after 
each meal, till the constipation is overcome. 

SECTION XXVI.— BILIOUS COLIC. 

By bilious colic, I mean that variety in which, in addition to the ordi- 
nary symptoms of colic, there is marked derangement of the digestive, and 
especially of the biliary organs ; the disease being attended with nausea 
and bilious vomiting. 

Bilious colic may be produced by various causes, but it appears to 
depend, in most cases, according to my observation, upon a malarious 
influence, the main force of which is concentrated directly upon the liver 
and alimentary canal, or else indirectly, the primary influence being 
exerted upon that portion of the spinal cord from which the liver and 
intestines are more immediately supplied with nerves. 

Symptoms, — Before the colic makes its appearance, the patient gene- 
rally experiences headache, loss of appetite, has a bitter taste in the 
mouth, and occasionally thirst, nausea, and bilious vomiting. After 
these symptoms have continued for an indefinite period, acute pains in 
the stomach and bowels supervene, moving at first from one part of the 
abdomen to another, but generally being most severe at the umbilicus, 
and very severe during the exacerbations. 

At first, pressure on the abdomen produces some relief, but as the dis- 
ease continues, the bowels may become tender to the touch, or to firm 
pressure at least. The pulse may be nearly natural, or depressed at 
first, but in the advanced stage of the disease it generally becomes in- 
creased in fullness, force and frequency. The hands and feet are some- 
times quite cold during the exacerbations of the pain. And usually 
about the second or third day of the disease, the eyes and skin assume 
a yellowish tinge. But in some instances the biliary symptoms appear 
several days before the abdominal pain commences. 

It is no uncommon occurrence for a paralysis of one or both of the 



400 DISEASES OF THE DIGESTIVE SYSTEM. 

superior or inferior extremities to occur during the continuance of this 
disease, and it is possible that the intestinal distension, when it occurs, 
may be in part of this character. The abdominal muscles may be spas- 
modically contracted in this disease, but more generally considerable 
tympanitis attends. 

Diagnosis. — The only diseases with which this affection is liable to be 
confounded are flatulent colic, peritonitis, gastro-enteritis, and hernia in 
some form. 

From flatulent colic it differs in being attended with marked bilious 
symptoms, and especially with bilious vomiting. From hernia it may 
be distinguished by a careful examination of the abdomen, together with 
the other symptoms which are developed. From peritonitis and gastro- 
intestinal inflammation bilious colic differs in the bilious symptoms which 
are developed, in there being less tenderness on pressure, and in the 
motions of the patient, which in the colic affection are generally quite 
free. 

Causes. — Koino-miasrnata appears to be the principal cause of this dis- 
ease, together with the effects of atmospheric vicissitudes, while the im- 
mediate cause of the local difficulty, it appears to me, is in part cerebro- 
spinal, there being generally spinal congestion, in consequence of which 
the functions of the liver become partially suspended, and to a great de- 
gree those of the alimentary canal. Now I suspect that the miasmatic 
agent acts through the blood upon the brain and nervous system, 
precisely as it does to produce bilious fever, but on account perhaps of 
slight irritation of the spinal marrow, or a predisposition to take on irri- 
tation, the dorsal portion of the spinal cord becomes congested, before a 
general febrile excitement is produced. This spinal congestion may, 
and probably does, affect more or less the whole length of the spinal 
marrow ; and hence the paralysis of the extremities, which sometimes 
occurs. 

But congestion does affect, I am confident, the dorsal portion of the 
spine, and it may be mainly of that portion, being attended with pain 
and more or less tenderness, in that portion of the spine more immedi- 
ately supplying nerves to the liver and alimentary canal. In conse- 
quence of this, in part, the liver becomes torpid, and the intestines in 
either a spasmodic or half paralyzed state, and hence, in part, the con- 
stipation, bilious derangement and colic symptoms which arise. 

Now it is, I believe, in consequence of this accidental predisposition 
to spinal congestion that bilious colic is produced, instead of regular 
bilious fever, which would otherwise be developed, sooner or later, in 
most cases at least. Atmospheric vicissitudes operate in conjunction 
with the paludal poison in producing bilious colic, very much as it does 
in the production of other bilious affections. When this disease is estab- 
lished, the functions of the liver are usually so far deranged, that either 
no bile is secreted, or else there is a copious secretion of acrid bile poured 
into the intestines, which irritates the alimentary canal, and produces, 
in part, the nausea and vomiting which occur in this disease. 

Prognosis. — Bilious colic, though a tedious, is not generally a very 
dangerous disease. But if the disease be neglected or mal-treated; 
serious, and even fatal results may reasonably be apprehended. 



LEAD COLIC. 401 

Treatment. — The indications in the treatment of bilious colic are to 
equalize the circulation, to counteract abdominal irritation, to evacuate 
the contents of the stomach and bowels, and to restore the functions of 
the liver and alimentary canal. 

Warm pediluvia, and stimulating friction along the spine should be 
resorted to at once, to equalize the circulation, as far as may be, for the 
time. Sinapisms should be applied over the abdomen, to counteract or 
prevent local inflammation of the abdominal viscera, and the vomiting 
may be aided by twenty or thirty grains of ipecac, with a little warm 
water. 

After the stomach has been sufficiently evacuated, five grains of Dover's 
powder, with two grains of calomel, may be administered every four hours, 
to allay pain, promote perspiration, and to affect the hepatic secretion. 
With the third or fourth dose of calomel and Dover's powder, half an 
ounce of castor oil may be administered, and the oil repeated, with each 
succeeding powder, till a free evacuation of the bowels are produced, the 
operation being assisted, if necessary, by injections of flaxseed tea, with 
half an ounce of castor oil, and one or two drachms of the oil of tur- 
pentine. 

In all severe cases, cups should be applied on each side of the spine, 
along the dorsal region, and a little blood taken, to overcome the con- 
gestion and slight irritation, which I am confident generally exists in a 
greater or less degree in this affection. In all obstinate cases of bilious 
colic, which do not yield to this treatment, blisters should be applied on 
each side of the dorsal spine, and also to the epigastrium and abdomen, 
if necessary. 

Crust coffee should be allowed at first, with mucilages, but later, 
broths, arrow-root, and toast may be allowed. If there be much pros- 
tration in this disease, after evacuating the stomach and bowels, two 
grain doses of the sulphate of quinine may be given every six hours, for 
a time, and during convalescence, a cold infusion of columbo may be 
allowed, in moderate doses, after each meal. If, when this disease sub- 
sides, the patient be left with paralysis of the intestines, or any other 
part, go-th of a grain of the muriate of strychnia may be given in solu- 
tion, after each meal, and continued till the paralysis is overcome. 

SECTION XXVII.— LEAD COLIC. 

By lead colic, I mean that variety of disease occurring generally from 
the effects of lead, and attended with colic, marked dyspepsia, and in 
some cases with paralysis, dropsy, and finally apoplectic symptoms. 

Symptoms. — Lead colic generally makes its appearance in a very gra- 
dual manner, commencing with symptoms of gastric derangement. The 
patient suffers from an irregular appetite, languor, foul eructations, con- 
stipation, nausea, transient abdominal pains, a feeling of stricture in the 
abdomen, drowsiness, and general languor, with depression of spirits, &c. 
Gradually the pain in the epigastrium and umbilical regions become more 
severe and constant, the abdomen is hard, retracted, and tender to ex- 
ternal pressure, and the bowels torpid, and stomach more or less irri- 
table. 

26 



402 DISEASES OP THE DIGESTIVE SYSTEM. 

The pain in the bowels is generally continuous, or has only slight remis- 
sions, the exacerbations of colic pains being protracted in duration, and 
exceedingly severe. The retching and vomiting is generally very dis- 
tressing for the first two or three days, only slight mitigation being ex- 
perienced immediately after vomiting. In violent cases, the pains pass 
from the umbilical region upwards to the chest and arms, and downwards 
to the pelvic viscera and lower extremities. 

During the exacerbations, cold sweats sometimes break out on the face 
and extremities; the countenance becomes contracted and pale; and if 
the disease continues, convulsions, and paralysis of the limbs, or some 
other part is liable to occur. In protracted unsubdued cases of this dis- 
ease, the abdominal pains may abate; the stomach become tender and 
distended; the thirst unquenchable; vision imperfect; and after the 
supervention of oedema of the feet, a livid countenance, and various 
other symptoms, the patient may die in an apoplectic state. 

In chronic cases of this affection, the gums at their margin, assume a 
leaden hue; the capillary circulation becomes inactive; the surface of 
the body becomes harsh and sallow ; the temper irritable, desponding, 
taciturn, and gloomy; the countenance is expressive of deep suffering; 
the body emaciates ; portions of the body become paralyzed ; the abdo- 
men tumid ; the legs cedematous, and finally mania, or total imbecility 
may ensue, and the patient ultimately die apoplectic, with dropsical 
effusions, in various parts of the body. 

The abdomen is generally retracted in this disease ; the bowels consti- 
pated; there is nausea, and bilious vomiting; the tongue is flabby and 
tremulous; the pulse either slow and hard, or moderately frequent; the 
breath offensive; the hand tremulous; and there is great weakness, with 
occasional cramps of the lower extremities. Such . are the ordinary 
symptoms of this variety of disease ; liable of course, to variations, ac- 
cording to the severity and duration of the affection, and the general 
constitution of the patient. 

Diagnosis. — Lead colic may be distinguished from flatulent, and bilious 
colic, by the circumstance of exposure to lead ; by the leaden hue of the 
countenance, and dark or bluish- gray color of the margin of the gums; 
by the nearly continuous abdominal pains; by the retracted abdomen, 
and by the pains in the extremities, as well as the occasional paralytic 
complications in this variety of disease. 

Anatomical Characters. — On the post-mortem examination of subjects 
dead of this disease, there are usually found traces of inflammation in 
the mucous membrane of the stomach and bowels. But the most fre- 
quent morbid appearance of the alimentary canal, is contraction at irregu- 
lar points of its muscular coats, so that the intestines will hardly, at the 
contracted points, admit a goose quill to pass, while the intervening por- 
tions are distended, forming irregular sacs, along the intestine. 

In one case that I examined in this village, about three years since, I 
found the ascending, descending, and transverse colon so contracted at 
points, as barely to admit the little finger. The mucous membrane of 
the stomach and intestines, in this case, presented signs of having been 
inflamed, and on the mucous membrane, at the pyloric extremity of the 
stomach, a pseudo membrane had been formed. In some protracted 



LEAD COLIC. 403 

cases of this disease, there is found hypertrophy of the brain, while in 
others, there is marks of congestion or irritation, with softening of the 
brain, or spinal cord. 

Cause. — Lead in some form, is probably the sole cause of this disease. 
Any of the preparations of lead, capable of being received into the sys- 
tem, through the stomach, lungs, or skin, may produce this affection ; 
but it is probable that the acetate, the carbonate, and the fumes of mel- 
ted lead as frequently operate to produce this disease, as any of its 
forms. Such, however, is the pernicious tendency of lead upon the hu- 
man system, that I very much doubt whether it should not be excluded 
from use, as a medicine, as a paint, and in fact in every capacity in 
which it can be brought to act, either directly, or indirectly upon man 
or beast, except perhaps as an instrument of death, to be hurled upon 
beings deserving of, and fitted for destruction. 

Lead operates through the blood directly upon the brain, spinal cord, 
and nervous matter generally, with which it comes in contact ; but more 
especially perhaps upon the spinal cord, and hence in part the colic and 
paralytic symptoms which are developed. In protracted cases, however, 
the brain becomes seriously affected by it, probably by the particles of 
lead becoming lodged in its tissue, in consequence of which, apoplectic 
and other like symptoms are developed. 

Lead appears to be equally poisonous to the lower animals as to man ; 
among the instances of which, that have fallen under my observation, I 
will mention one, illustrating its pernicious effects upon swine. 

A few years since while practising in Jefferson county in this state, I 
was requested by a gentleman to look at his hogs, as he had a large 
number sick and some already dead. They appeared to suffer from 
severe colic pains, and there was some distension of the abdomen. They 
had great thirst, and those in the latter stages exhibited decided apo- 
plectic symptoms. 

The gentleman had suspected poisoning from the conium maculatum 
which grew abundantly in the field ; but so decidedly did their symp- 
toms indicate lead, as the cause, that I inquired if they had been exposed 
in any manner to lead, and I found, on further inquiry, that a few days 
previous an apparatus consisting of a copper pump and lead pipe, had 
been arranged for the purpose of conveying the sour whey from its 
reservoir to the trough, from which the hogs eat three times a day. 

The mystery was at once solved, and the pump and lead pipe being 
removed, no more hogs were taken sick, and those already sick, that had 
not reached an apoplectic state, gradually recovered with no other pre- 
scription than a moderate allowance of food for a few days. I ex- 
amined the intestines of the surviving hogs after they were fatted and 
killed, and found them so contracted, at points, as scarcely to admit a 
crow-quill, the intervening portions being very much dilated, so as to ap- 
pear in some places like large bladders. From such facts, we may form 
some idea of the pernicious effects of lead not only upon the human 
species, but also upon the lower animals ; and we may infer, to some 
extent, the condition of patients suffering from occasional attacks of 
lead colic. 

Pathology. — It is probable that the particles of lead, however, intro- 



404 DISEASES OF THE DIGESTIVE SYSTEM. 

duced into the system, become lodged in the brain, spinal cord, and 
nervous matter in different parts of the body, and being too large for the 
mouths of the absorbent vessels, it acts as a direct irritant or poison, not 
being soluble in the fluids with which it comes in contact. That portion 
of the particles of lead lodged in the brain, probably produces, in part, 
the irritation or cephalic derangement which leads on to the apoplectic 
and other cephalic symptoms which are sometimes developed. That por- 
tion lodged in the spinal marrow may, by affecting its nerves, account for 
the intestinal contractions, and pains, and paralysis of the extremities. 
And the lead in other parts of the system may and probably does inter- 
rupt the functions of the parts, by deranging the flow of nervous in- 
fluence and deranging the capillary circulation. 

From the presence, then, of these insoluble particles of lead in the 
brain, spinal cord, and other parts of the system, we have accounted for 
the leaden hue, the dropsical effusion, the paralysis, the intestinal con- 
tractions, and also the apoplectic and other cephalic symptoms which are 
developed in this disease. 

Prognosis. — Lead colic, as it indicates the presence of considerable of 
the mineral in the system, always affords ground for reasonable apprehen- 
sion in relation to the ultimate result of the case. If, however, the 
patient can be removed from further exposure to the poison, and can 
have the benefit of proper treatment, for a reasonable time, hopes may 
be entertained of a partial and perhaps entire removal of the lead from 
the system, and of a partial recovery, at least, from its pernicious effects. 
Treatment. — At the commencement of lead colic, dry cupping along 
the spine may be resorted to, and this, with sinapisms to the abdomen, 
will often allay the most urgent symptoms. Five grains of Dover's 
powder with three of calomel, should be given every four hours, and with 
the third powder, half an ounce of castor oil may be given, and the oil 
continued with each succeeding powder, till a free evacuation of the 
bowels is produced. Should the oil be slow in producing its effects, it may 
be aided by injections of flax-seed tea, with half an ounce of castor oil, and 
a tea-spoonful of the oil of turpentine if necessary. After the operation of 
the cathartic, the calomel should be suspended, and the Dover's powder 
continued every six hours, and the dose of this should be gradually 
diminished till the pain and other active colic symptoms subside. 

After suspending the calomel, and getting a free evacuation of the 
bowels, the iodide of potassium may be given in five grain doses every 
six hours, alternating with the Dover's powder ; this should be given 
with a view of removing the lead from the system, which it does by first 
uniting with it and forming an iodide of lead, which is then removed by 
the absorbents, and carried from the system with the various excretions. 
After discontinuing the Dover's powder, the iodide of potassium may be 
given in six or eight grain doses, three times per day, before each meal, 
and continued for several weeks, or months, if necessary, in order to 
remove every particle of the lead from the system if possible. 

I am satisfied, by careful observation, that lead may thus be removed 
from the system, and in one case in which there had been paralysis of 
one leg for several months ; there was not only a return to health from 
the long continued administration of the iodide of potassium, but the 



INTUSSUSCEPTION. 405 

paralysis was also restored. In cases, however, in which paralysis 
remains, after the lead is removed from the system, the muriate of 
strychnia in ^th of a grain doses may be administered in solution, till 
the paralysis is overcome. 

SECTION XXVIII.— INTUSSUSCEPTION. 

By intussusception, I mean here the introduction of one part of the 
intestines into another, either direct or retrograde. It is direct where 
the upper part of the intestine is passed into the lower ; but retrograde 
when the lower portion is passed into the upper. 

Direct intussusception is generally produced by augmented peristaltic 
action of the intestine, forcing the superior portion into the lower, while 
an inverted action of the intestine, such as is produced when vomiting 
occurs, forces a lower portion into the upper, and so produces the retro- 
grade variety. Intussusception may take place in any part of the 
alimentary canal, but in cases that have fallen under my observation, it 
has been in the ileum, near its termination in the colon. 

Symptoms. — We have in this affection most of the symptoms of spas- 
modic colic. There is generally pain in the abdomen, eructations of 
wind, frequent and ineffectual efforts at stool, distension of the abdomen, 
and constipation ; only slight evacuations occurring from that portion of 
the intestines below the seat of the disease. In some cases there is hic- 
cough, and vomiting of stercoratious matter, from that portion of the 
intestine above the seat of disease. 

If the disease continues, symptoms of intestinal inflammation sooner 
or later supervene, and if the inflammation be severe, and continued for 
a considerable time, gangrene and mortification of the intestine will be 
the result. This will be indicated by a cessation of the pain, prostration 
of strength, rigors, and all the usual symptoms of mortification. 

Sometimes, however, the invaginated portion of the intestine sloughs 
away, and is discharged, and the patient finally recovers, by a sponta- 
neous effort of nature. Or if no inflammation occur, or it be early sub- 
dued, there may be a spontaneous disengagement of the enclosed portion 
of the intestine, and so the patient recover. By carefully passing the 
hand over the abdomen, in this disease, a hard, irregular tumor may 
sometimes be felt, indicating the seat and extent of the invagination. 

Diagnosis. — It is exceedingly difficult to distinguish this disease from 
ordinary colic, but if it follow the operation of a drastic cathartic, or 
severe vomiting, and a tumor be distinctly felt in the abdomen, and 
apparently connected with the intestine, intussusception may be strongly 
suspected, especially if the constipation cannot be overcome. 

Causes, — Direct intussusception may be produced by any cause capa- 
ble of producing an increased peristaltic action of the intestines, such as 
drastic cathartics, intestinal worms, and other irritating agents. Any 
cause capable of inverting the action of the intestines, may produce the 
retrograde variety, such as emetics, intestinal worms, &c. It is possible 
that this disease may be produced, in some cases, by mere relaxation 
of the intestines ; a very slight direct or inverted action being sufficient, 
in such cases, to produce either the direct or retrograde form of the 
disease. 



406 DISEASES OF THE DIGESTIVE SYSTEM. 

Prognosis. — This is always a dangerous affection, from the liability of 
inflammation, gangrene and mortification, as well as from the intestinal 
obstruction. But a spontaneous cure is always to be hoped for, and 
some hope may be reasonably entertained, from proper remedial mea- 
sures, if early and judiciously applied. 

Nature. — When either variety of intussusception occurs, the intestine 
becomes irritated, a spasm is produced, inflammation occurs, and the 
portion of intestine involved becomes strangulated, and if not relieved, 
gangrene may be the result. That part of the intestine immediately 
above the seat of the disease, is generally enlarged or distended, with 
the contents of the intestine, while that part below, has generally a con- 
tracted appearance as might be expected. 

Treatment. — The indications in the treatment of intussusception are 
plainly to prevent or subdue inflammation, to overcome spasm, and if 
possible, to overcome or reduce the invagination by cathartics or emetics, 
according as the disease is direct or retrograde. 

In cases in which this disease is strongly suspected, cups should be 
applied on each side of the spine opposite the affected part, and three or 
four ounces of blood taken. And if symptoms of inflammation occur, cups 
should also be applied over the seat of the disease, and two or three ounces 
of blood taken. After the cupping a plaster of the extract of stramo- 
nium may be applied over the spine, opposite the affected part, with a 
hope of still further relaxing the spasm, and if no inflammation arise, 
another may be placed over the seat of the invagination to allay pain, 
and also to relax spasm, by which the intestine is liable to become 
strangulated. 

If now it appears that the intussusception was produced by an increased 
peristaltic action of the intestine, as from a drastic cathartic, an emetic 
of ipecac may be administered, with a hope of inverting the action of 
the intestine, and thereby overcoming the morbid condition, or drawing 
up that portion of the intestine which had been passed down into the 
lower. But if it appears that the intussusception was produced by an 
inverted action of the intestine, as by vomiting, a cathartic of calomel 
and castor oil may be given, with a hope of reducing the difficulty, or 
carrying down the invaginated portion of the intestine, by increasing the 
peristaltic intestinal action. 

Thirty drops of the tincture, or ten drops of the fluid extract of stra- 
monium, may be given every six hours, in part to allay pain, and also 
as an anti-spasmodic. If tenderness, with febrile excitement supervene, 
a large blister should be applied over the affected part, and thus the 
intestinal inflammation be if possible subdued. 

Such are plainly the indications of this obscure and truly dangerous 
affection. And while there is really no very strong grounds for hope in 
these cases, they should never be abandoned, as spontaneous cures have 
sometimes occurred after the most unpromising symptoms have been 
developed. During the continuance of this disease, the patient should 
be nourished by milk, or broths of a nourishing character, so that as 
little bulk of food as possible may be taken. 



CONSTIPATION. 407 



SECTION XXIX.— CONSTIPATION. 



By constipation, I mean here that state of the bowels in which the 
evacuations are less frequent, or less in quantity than is requisite for a 
perfect state of health, the discharges being generally hard, and pro- 
cured with more or less difficulty. If there is not a daily movement of 
the bowels, it is generally in consequence of diminished secretion of the 
mucous membrane, of hepatic derangement, or else diminished action, or 
paralysis of the muscular coat of the intestines. 

Symptoms. — If constipation of the bowels continue for any conside- 
rable time, there is, in addition to the omission of daily stools, and the 
difficulty of procuring them, a long train of unpleasant symptoms deve- 
loped, in most cases at least. The breath becomes offensive, the mouth 
foul and dry, the tongue is furred in the morning, the appetite becomes 
variable or indifferent, there is apt to be acidity of the stomach, with 
nausea, flatulence and headache, and if the constipation be protracted, 
it is liable to produce piles, by the undue pressure which occurs along 
the hemorrhoidal veins. 

Very protracted constipation not only irritates the alimentary cajial, 
but it also deranges the functions of the abdominal and pelvic viscera, 
produces a cephalic tendency, and finally, by deranging the blood, im- 
pairs the health, tone and vigor of the whole system. 

Causes. — Constipation may be caused by an astringent diet, by the 
use of opium, by neglect of the calls of nature, stricture of the bowels, 
softening or congestion of the brain, by disease of the spinal cord, by 
pressure of the uterus during pregnancy, and by paralysis of the mus- 
cular coat of the intestines. 

The worst and most troublesome varieties of constipation may be pro- 
duced by the long continued use of diuretics, the renal secretion robbing 
the alimentary mucous membrane of its due amount of fluid, with which 
to moisten the fecal matter. The same condition is also produced by too 
frequent bathing, or washing the surface of the body; the skin in such 
cases being excited to undue action, and robbing the kidneys and ali- 
mentary mucous membrane, and even causing to be taken up from the 
fecal matter its fluid parts, rendering it dry, and its passage along the 
intestines very difficult. 

The worst direct and general or constitutional effects that I have ever 
witnessed from constipation, was produced in a child three years of age, 
from having been washed all over daily from birth in warm water. It 
was corrected by washing less frequently, and substituting coolish for 
warm water, and giving for a time a solution of the sulphate of magnesia 
and rhubarb. 

Treatment. — In prescribing for constipation, an effort should always 
be made to correct the condition by removing the cause, and directing a 
proper diet, and also directing due attention to the calls of nature, once 
each day, at a regular hour. In this way many cases may be corrected, 
with no other remedy than ripe fruit, with, or immediately after meals, 
and, if necessary, the use of bread made from unbolted flour. If these 
measures fail, and there is no hemorrhoidal affection, a pill of two grains 
each of aloes and rhubarb may be given after dinner each day, for a 



408 DISEASES OF THE DIGESTIVE SYSTEM. 

time, and then omitted, one being taken at evening, if there has been no 
movement during the day, and thus continued till the constipation is 
entirely overcome. 

In cases, however, in which the constipation appears to depend upon 
a torpid state of the liver, a blue pill may be given at evening, for two 
or three days, at first, and then followed with the pill of aloes and rhu- 
barb, or what may do better, in such cases, with the decoction of dande- 
lion, or else the fluid extract, in moderate doses, after each meal. If 
the fluid extract of taraxacum be used, from half a drachm to a drachm 
may be given after each meal; but if the decoction, it may be made by 
boiling four ounces of the fresh roots and tops, in a pint and a half of 
water, down to a pint, of which a wine-glassful may be given after each 
meal, till the constipation is overcome. 

In cases of constipation depending upon a torpid or paralyzed condi- 
tion of the bowels, and attended with a hemorrhoidal complication, the 
muriate of strychnia may be given in ^th of a grain doses, in solution, 
three times per day, till the constipation is overcome. 

In cases of constipation in females, during pregnancy, if there is aci- 
dity of the stomach, a teaspoonful of calcined magnesia may be given 
each morning, and repeated at evening, if necessary, till the constipa- 
tion is overcome. In cases in which the magnesia is not sufficient alone, 
a teaspoonful may be given in the morning, and a teaspoonful of castor 
oil at evening, if necessary. 

Constipation occurring in children, between six months and two years 
of age, may generally be corrected by giving a solution of the sulphate 
of magnesia and rhubarb for a time. A drachm of each may be dissolved 
in half a pint of water, and of this from half a teaspoonful to a teaspoon- 
ful may be given each morning, and repeated at evening, if necessary, 
till the bowels are regulated. 

Constipation in early infancy may generally be corrected either by the 
use of soap suppositories, or else by giving every morning, and repeating 
at evening, if necessary, half a teaspoonful of a mixture of pure sweet oil 
and molasses ; of each equal parts. 

SECTION XXX.— INTESTINAL WORMS. 

By intestinal worms, I mean those worms which are so often found in 
the intestines of the human species. The intestines of the human spe- 
cies sometimes contain different species of worms, the most frequent of 
which are the tricocephalus dispar, or thread worm ; the ascaris vermicu- 
laris, or seat worm ; the ascaris lumbricoides, or round worm ; the taenia 
lata, or broad tape-worm ; and the tsenia solium, or common tape-worm. 

The tricocephalus dispar, or long thread-worm, is about two inches in 
length, two-thirds of which is almost as thin as a horse-hair, the remain- 
ing and posterior third, being considerably larger, terminating in a round 
blunt extremity. These worms are seldom met with, and when they do ex- 
ist, are generally found in the caecum or large intestines. 

The ascaris lumbricoides, or round worm, is from two to twelve inches 
in length ; round, of a yellow or brownish-red color, of nearly a uniform 
thickness, except at the extremities, which taper to a blunt point, and 



INTESTINAL WORMS. 409 

are generally about three lines in thickness. These worms generally 
inhabit the small intestines, but occasionally they ascend into the sto- 
mach, and they are by far the most frequent variety of intestinal worms. 

The ascaj'is vermicularis, or seat worm, is a very small white worm, 
from two to six lines in length, and terminating in an extremely fine ex- 
tremity posteriorly, resembling the point of a fine needle. These worms 
usually occupy the large intestines, and especially the lower portion of 
the rectum, where they are sometimes collected in great numbers. 

The taenia lata, or broad tape-worm, is about eight lines in breadth, 
it is fiat, white, and composed of a series of connected joints, resembling 
a piece of white tape. The head is armed with two processes, by which 
the worm attaches itself to the intestines. This variety of worm in- 
habits the stomach and upper portion of the intestines, and often acquires 
a very great length, sometimes even thirty or forty feet. 

The taenia solium, or common tape- worm, is composed of joints resem- 
bling very much the seeds of the gourd, especially in the lower or poste- 
rior part of the worm. The anterior portion of this variety tapers off in 
a fine thread-like extremity ; the head being extremely small, and fur- 
nished at its sides with four raised disks, with depressed centres, by which 
the animal probably attaches itself to the intestine. This variety of 
tape-worm inhabits the stomach and small intestines, and generally comes 
off in pieces, from a single joint to several feet in length. 

Other animals are said to be found in the alimentary canal, but the 
preceding are the only varieties which appear to be peculiar to this 
situation, so that if others are found there, it may be regarded as acci- 
dental ; either the eggs or animals themselves having been taken with 
food or drinks. 

Symptoms, — There are few, if any, positive symptoms of intestinal 
worms ; but symptoms often arise by which we may suspect the existence 
of worms in the alimentary canal, and if the ova of worms can be dis- 
covered in the discharges of persons suspected, by microscopic examina- 
tion, that may be regarded as positive evidence of their presence. 

The symptoms most frequently met with in patients annoyed by worms, 
according to my observation, are a pale countenance, or a livid appear- 
ance, with occasional transient flushes, dull eyes, and dilated pupils, with 
a bluish semicircle around the lower lid, itching of the nose, tumid upper 
lip, headache, copious secretion of saliva, furred tongue, foul breath, 
and variable appetite, being at times voracious, and at others entirely 
gone. 

In some cases there is vomiting, pains in the abdomen, especially in 
the umbilical region, slimy stools, turbid urine, a tumid abdomen, ema- 
ciation, lassitude, irritability of temper, and general convulsions. And 
in some rare cases there is an obstinate cough, palpitation, and a general 
debilitated and irritable condition of the system produced, leading to 
melancholy, hypochondria, insanity, &c. 

It appears to me that worms cannot be regarded as harmless inmates 
of the intestinal canal, at least in the present physically depraved con- 
dition of the human family. It is probable, however, that if the laws of 
health had always been observed, there would be no intestinal worms, or 
existing, they would be entirely harmless. 



410 DISEASES OF THE DIGESTIVE SYSTEM. 

It appears, according to my observation, that those who have adhered 
most rigidly to the rules of propriety, especially in relation to taking 
good, wholesome food, and at regular hours, are comparatively free from 
the annoyance of intestinal worms, while those who have departed most 
widely from these rules, suffer most from verminous irritation. In rela- 
tion to the origin of the different varieties of intestinal worms, there may 
be room for reasonable doubt; but it appears possible that they may be 
derived from ova introduced into the system with food or drink when 
taken in a raw or uncooked state. 

Treatment. — The treatment proper for the expulsion of worms, de- 
pends very much upon the variety of the worm and the general condition 
of the patient at the time of the treatment for their expulsion. But as 
the indications for the expulsion of the round worm and long thread 
worm is the same, we may first inquire into the treatment proper when 
they are suspected, and then we may consider, in turn, the treatment 
proper for the destruction of the seat-worm, and finally of the tape-worm. 

For the ordinary worm affections of children or adults, if the seat- 
worm or tape-worm is not suspected, there is no remedy that so generally 
does well as the spigelia marilandica, or pink root. It may be given in 
infusion, half an ounce of the pink root being infused in a pint of water 
in a covered vessel, for one hour. Of this infusion a table-spoonful may 
be given to a child one year old, morning, noon and night, in sweetened 
water, with a little milk; and for each additional year of age half an 
ounce more of the infusion may be given; no more than six ounces, how- 
ever, should be administered to an adult at one time. 

The better way, however, to arrive at the dose for children in this as 
well as in all other cases, is to call six ounces of the infusion a dose for 
an adult, and then arrive at the dose for a child by the rule laid down 
in the early part of this work, as follows : Divide the age of the child 
increased by twelve, by itself, and the quotient will indicate the propor- 
tion for the child. Thus, if the child be six years old, that increased by 
twelve makes eighteen, and eighteen divided by six gives a quotient of 
three ; so that the dose for a child six years old will be one-third of that 
for an adult, or two ounces. By this simple rule, as before stated, the 
dose of any medicine for children may readily be arrived at; due allow- 
ances being made for constitutional peculiarities, &c. 

The pink should be given with the meals, morning, noon and night, 
for three days, and on the fourth day a dose of calomel and castor oil 
should be administered so as to procure a thorough evacuation of the 
bowels. The pink probably has a narcotic effect upon the worms, so 
that by giving it with the food for three days, they become stupefied, 
and are readily removed by the calomel and castor oil, or they might be 
by the oil alone in case the calomel, from any cause, is contra-indicated. 

Instead of the infusion of pink root, the fluid extract may be given, if 
at hand. Of this, from half a drachm to a drachm may be given to an 
adult in the manner I have suggested for the infusion, the dose for 
children being arrived at as I have already suggested; or, what in some 
cases may do better, the fluid extract of spigelia and senna may be given 
in one or two drachm doses to adults, and continued at meals for three 
days, only a moderate dose of calomel and oil being required on the 
fourth day, as the senna may produce slight relaxation of the bowels. 



INTESTINAL WORMS. . 411 

In cases in which, from any cause, the spigelia is contra-indicated, the 
chenopodium anthelminticum, or worm-seed, may be given instead. Ten 
grains of the pulverized seeds, or five drops of the oil, may be given to 
a child one year old, morning and evening, for three days, and on the 
fourth day, a dose of calomel and castor oil may be administered, or the 
oil alone, if the calomel be contra-indicated. For adults, sixty drops of 
the oil, or two drachms of the pulverized seeds, may be given at a dose, 
in the same manner, a full dose of calomel and oil being administered 
on the fourth day, as directed for children. 

In all cases of verminous irritation, in which the pink and worm-seed 
are contra-indicated, or inappropriate, a full dose of calomel and castor 
oil may be given at once, and generally with very good effect. Such, 
according to my observation, is the most safe, convenient, and effectual 
method of destroying the common round worm, in children and adults, 
and the same treatment is applicable in case the long thread-worm is 
suspected. 

In the destruction of the ascaris vermicularis, or seat-worm, which, as 
we have seen, inhabits and often irritates the lower part of the rectum, 
there is generally more or less difficulty. The tincture of aloes and 
myrrh, in drachm doses for adults, and less for children, according to 
the age, may be given every morning, for two or three weeks, and an 
injection of cool water used at evening, for a time, and then, with the 
addition of half an ounce of common salt, for an adult, will generally 
exterminate them, if continued for a reasonable time. 

If, however, this treatment fails, an injection of equal parts of lime- 
water and milk may be used. Or in case this should fail, one drachm 
of the oil of turpentine, in a gill of milk, may be used once each day, at 
evening, instead. After having continued this treatment for two or 
three weeks, a full dose of castor oil, or calomel and oil, may be given, 
and a free operation secured. And should the worms find their way 
into the vagina, injections of vinegar and water may be used for a time. 
In this way, I believe, this troublesome variety of worm may generally 
be temporarily or permanently destroyed. 

For the removal of the tape-worm, the oil of turpentine is a valuable 
remedy, for either variety. The oil of turpentine may be given in 
drachm doses, in a little water or mucilage, three times per day, for 
three days or longer, and then a full dose of castor oil administered. 
Or an ounce of the turpentine may be given at once, and a full dose of 
castor oil administered in two hours, and repeated if necessary. 

I believe this treatment will generally prove successful, but in case it 
fails, or if there is some good reason why the turpentine should not be 
given, I would use the pumpkin seeds, prepared as follows. Six ounces 
of the pumpkin seeds may be bruised thoroughly in a mortar, without 
removing the shells, and then sufficient water should be added to give, 
by straining and expression, a pint of liquid. Of this one-half may be 
administered early in the morning, and in two hours an ounce of castor 
oil should be given. About noon the remaining half of the liquid should 
be given, and this also followed in two hours by an ounce of castor oil, 
which may be repeated in two hours, if necessary. 

Should the treatment prove successful, the tape worm will generally 



412 DISEASES OF THE DIGESTIVE SYSTEM. 

be discharged during the operation of the second dose of castor oil. In 
case the turpentine and pumpkin seeds fail of producing the expulsion 
of the tape worm, two ounces of the bark of the pomegranate root may 
be bruised and macerated in a quart of water for twenty-four hours, and 
then the mixture should be boiled down to a pint. Of this a wineglassful 
should be given every hour till the whole is taken, or till nausea, vomi- 
ting and free purging is produced, at which time the worm may be ex- 
pelled with the discharges. In some one of these methods, I believe the 
tape worm may generally be destroyed. 

In selecting a remedy from the ones I have suggested for the destruc- 
tion of the tape worm, as well as for the other varieties of worms, the age, 
constitution, hereditary and acquired constitutional peculiarities of the 
patient should be taken into account; and generally the milder mea- 
sures should be resorted to first, and the more active resorted to only in 
case of failure with the milder measures. Care should be taken that an- 
thelmintics be not continued for an unreasonable time, or administered in 
cases in which the disease is from irregularity of eating and not from 
intestinal worms. 

Nothing is more common, according to my observation, than for 
parents to allow their children to take improper food, or to eat at all 
hours, and thus destroy their digestive powers ; producing most of the 
symptoms usually developed from the presence of intestinal worms. The 
child in such cases has an irregular appetite, grows pale, loses flesh, be- 
comes irritable during the day and restless nights, becomes pale about 
the mouth, picks its nose, &c. ; and if the irregular eating be continued, 
I have known dropsy, epilepsy, convulsions, &c, to be the result. 

Now all this is generally charged by the parents to worms; and if the 
diseases which the reckless and ruinous indulgence in irregular eating 
has produced does not kill the child, the thousand and one worm nos- 
trums which may be prescribed is very likely to. Now it is probable 
that this imprudence together with filthiness, bad air, &c, may and does 
favor perhaps the generation and growth of intestinal worms, but a large 
majority of the cases of the character I have described, that have fallen 
under my observation, which have been attributed to worms, are the 
direct result of taking food at irregular hours or eating between meals. 

As a general rule then, when children or adults exhibits symptoms, 
such as I have described, it is best to inquire carefully into the habits of 
the patient in relation to taking proper food at regular hours, &c, that 
no more be charged to worms than they are guilty of. And in all cases 
a plain, digestible and proper diet should be insisted on, and enforced if 
necessary, and then if there be substantial reasons for suspecting intesti- 
nal worms, the measures I have suggested may be resorted to for their 
destruction. 

SECTION XXXI.— HEMORRHOIDS— {Piles.) 

By hemorrhoids from 'a^a, " blood", and pc «, "I flow," I mean that 
disease of the lower portion of the rectum, in which there is generally 
erectile tumors, either within or around the extremity of the bowel, 
which occasionally pour out more or less blood, and are very liable to 
become inflamed. 



HEMORRHOIDS. 413 

It will be remembered that the rectum is supplied with blood by the 
superior middle, and inferior hemorrhoidal arteries, while its veins 
empty mainly into the inferior mesenteric, thus forming a part of the 
portal circulation. Now when we remember that the veins of* the rec- 
tum have no valves, that they form a part of the portal circulation, 
returning the blood from the lower part of the rectum, it cannot appear 
strange that hemorrhoids or piles should occur. The liability to this 
disease is increased by the possibility of an interruption to the free 
passage of the blood of the portal vessels through the liver, and also by 
the passage down the rectum, of hardened or dry fecal matter. 

If now there be a relaxed condition of the tissues generally, a con- 
gested state of the portal vessels, and a constipated state of the bowels, 
the veins of the rectum, as well as its mucous membrane, are liable to 
become congested and more or less irritated, and hence the different 
varieties of hemorrhoidal tumors, which being formed, and inflamed, 
develop the symptoms peculiar to each. 

The same causes favor an enlargement, or a varicose state of the 
hemorrhoidal veins, for six or eight inches up the rectum. And as these 
veins lay immediately under the intestinal mucous membrane, and are 
surrounded by a sub-mucous or cellular tissue, these parts are very 
liable to become more or less congested, as well as the hemorrhoidal 
veins. 

We have then in consequence of all these predisposing circumstances, 
various forms of hemorrhoidal tumors, the most important of which are 
the varicose, the erectile and the fleshy tumors, each of which are formed 
as follows : 

The varicose hemorrhoidal tumors arise from a varicose state of the 
hemorrhoidal veins ; are situated at the lower extremity of these veins ; 
consist of an enlargement without rupture of these vessels, and are covered 
only by the mucous membrane of the rectum. They form slowly within 
the bowel, and become gradually extended, as they become larger, and 
consist of a round, tense, elastic nucleus the size of a pea, covered by the 
intestinal mucous membrane which moves easily upon it. When this 
tumor remains extended, the blood which it contains may coagulate, lymph 
may be effused, and finally it becomes organized and vascular, its mucous 
membrane becoming strongly adherent, and thus it constitutes one 
variety of bleeding piles. 

The erectile tumor consists of the mucous, sub-mucous, and cellular 
tissues of the lower part of the rectum, supplied with blood from one or 
more of the hemorrhoidal veins, in consequence of which, they frequently 
become of large size, and present all the characteristics of an erectile 
tissue. These tumors are cellular, spongy, full of blood, very vascular, 
and bleed profusely from innumerable points on their surface. They 
form within the intestine, from congestion of the mucous, sub-mucous 
and cellular tissue . And as they enlarge, they are mechanically pro- 
truded from the rectum, and constitute the cellular or erectile variety of 
bleeding piles. 

The fleshy tumor, or blind pile, consists wholly of dense, thickened 
or hypertrophied cellular tissue, covered by the intestinal mucous mem- 
brane, and are from their earliest formation external. These tumors 



414 DISEASES OF THE DIGESTIVE SYSTEM. 

probably begin in merely a small fold of the mucous membrane, which, 
with its sub-mucous tissue has been forced from the bowel in an effort at 
stool, and being pinched by the sphincter, is prevented from returning 
within the bowel. Exposed thus to friction, these tumors become in- 
flamed; in consequence of which, they are thickened and indurated, 
their mucous-investing membrane becoming transformed into skin, and 
in this way the whole tumor becomes a chronic pile, more or less insen- 
sible until active inflammation is excited; when it swells, grows red, 
hard, and extremely painful, but does not bleed. By continued irrita- 
tion these tumors sometimes increase to a large size, and if there are 
several, their opposing surfaces may become ulcerated, and thus an 
offensive purulent discharge take place. 

Hemorrhoidal tumors generally have a broad base, but sometimes they 
are more or less pedunculated, and in an indolent condition they may be 
pale and flaccid; but when inflamed, or highly congested, they become 
red or purple, tense, hard, and exceedingly tender and painful. 

Hemorrhage is liable to occur in this disease from the varicose veins, 
from the capillaries of the rectum, by exudation from the tumors, and 
also from the intestinal mucous membrane. When the hemorrhage is 
from a rupture of the varicose veins, it may come on in a stream, while 
the patient is at stool; but when it occurs from the capillaries of the 
rectum, or by exudation from the surface of the erectile tumors, or from 
laceration of the intestinal mucous membrane, it is generally less rapidly 
copious. 

Symptoms. — The symptoms of hemorrhoids are just such as we should 
suppose would arise from a determination of blood to the rectum, with 
congestion of the hemorrhoidal vessels, together with the presence of 
indolent, irritable, or inflamed tumors either within or projecting from 
the extremity of the rectum. 

There is generally at first a feeling of heaviness or fullness, soon 
followed by pain in the extremity of the bowels, which extends to the 
surrounding parts. This pain may be continuous, or it may subside and 
return again in a few days with increased severity, till finally a small 
tumor or tumors are discovered, which are generally more or less tender, 
at times, at least. 

When a determination of blood to the rectum occurs, which immedi- 
ately precedes hemorrhage, there is a dull pain in the back and a sense 
of heat about the sacrum; the urine is scanty and high-colored; there 
is heaviness in the head, and more or less disturbance of the digestive 
functions. These symptoms may go on increasing for several days, 
when the flux supervenes and entirely relieves the patient; being, of 
course, most marked in cases in which it occurs at regular periods. 

In cases of this affection in which there is habitual constipation, there 
is a sense of fullness, weight and heat almost constantly about the 
rectum, and generally more or less sympathetic irritation of the bladder, 
vagina and uterus in females ; all of which symptoms may be tempo- 
rarily alleviated by the flow of blood, but not entirely, the irritation 
being kept up by each movement of the bowels. 

When inflammation of hemorrhoidal tumors takes place from consti- 
pation, walking, riding or any other cause, the tumors become congested, 



HEMORRHOIDS. 415 

swelled, red or purple, and exceedingly painful, sometimes obliging the 
patient to keep his bed for several days. 

Diagnosis. — There is little difficulty in distinguishing piles from dysen- 
tery, prolapsus ani, polypus of the rectum, or hemorrhage from a higher 
portion of the intestines, if the history of the case and all the symptoms 
be carefully taken into the account. If, however, there is a possibility 
of confounding this disease with hemorrhage from the intestines higher 
up, it is only necessary to remember that the blood from the piles is 
fluid, florid, and generally discharged before or after a movement of the 
bowels, but never mixes with the discharges ; while blood from the intes- 
tines higher up, may be mixed with the feces, is often black and gene- 
rally coagulated. 

Causes. — Among the most frequent causes of hemorrhoids, are a 
hereditary predisposition, constipation of the bowels, free living with 
a sedentary mode of life, and aloetic or other drastic purgatives. 

The hereditary predisposition to piles consists in a general relaxed 
condition of the tissues, and especially of the cellular, which greatly 
favors, as we have seen, the formation of hemorrhoidal tumors. 

Constipation of the bowels by the mechanical irritation which it pro- 
duces in the lower portion of the rectum, becomes a frequent cause of 
hemorrhoids, and probably the most frequent cause. 

By free living, or taking too much stimulating food, digestion is im- 
paired and an irritation set up along the alimentary mucous membrane ; 
and along with hepatic derangement, there is produced congestion of the 
portal vessels, and so of course of the hemorrhoidal veins, and thus the 
formation of hemorrhoidal tumors is favored. 

A sedentary mode of life also, by favoring hepatic and portal conges- 
tion, produces or predisposes to hemorrhoidal affections. And finally, 
aloetic and other drastic purgatives probably produce piles by the direct 
irritation they produce in their operation upon the rectum. Besides the 
causes enumerated, there are other occasional causes of piles, such as 
suppression of the menses, pregnancy, irritating injections, ascarides, ve- 
nereal excesses, straining at stool, direct irritants, riding on horseback, &c. 

Treatment. — The indications in the treatment of hemorrhoids, are 
those which arise from the flux or hemorrhage, and those which occur 
from the tumors both in their ordinary and inflamed condition. In order 
to prevent the flux, it is necessary to correct the constipation of the 
bowels, as well as the torpid condition of the liver and congestion of the 
portal vessels. 

Constipation of the bowels and torpor of the liver may generally be 
overcome by a regulated diet, regular habits, a blue pill at evening for a 
few nights, and then by the administration of the decoction or fluid ex- 
tract of taraxacum, in moderate doses after each meal for a time. If, 
however, this should fail of correcting the constipation, a partially 
paralyzed condition of the bowels may be suspected as the cause, and 
the muriate of strychnia in g V of a grain doses should be administered in 
solution, three times a day till the constipation is overcome. 

To stop the hemorrhage when it occurs, ipecac in one-fourth of a 
grain doses, every fifteen minutes is a valuable remedy, and if necessary, 
tannin may be given in two grain doses every two hours, till it be ar- 



416 DISEASES OF THE DIGESTIVE SYSTEM. 

rested. If, however, the hemorrhage occurs in a debilitated patient, 
and is of a passive character, the tincture of the chloride of iron may 
be given in ten drop doses, every four or six hours, and continued till 
the hemorrhage is arrested. 

The patient during the continuance of the hemorrhage should be kept 
in the horizontal position, and injections of cold water used, and if the 
bleeding be obstinate, a saturated solution of alum in cool water may be 
resorted to. If, now all these measures fail, the tampon should be used 
if necessary. For this a piece of soft silk or linen moistened in a satu- 
rated solution of alum should be pressed carefully into the bowel. This 
will mechanically arrest the flow of blood, while the alum produces an 
astringent effect upon the hemorrhoidal vessels, and upon the surround- 
ing mucous and cellular tissues. 

Having thus by proper treatment overcome the hepatic and portal 
congestion, arrested the flux, and regulated the bowels, the tumors may 
be greatly relieved, and their inflammation and hemorrhagic tendency 
lessened by the daily injection of cool water, by sponging the anus morn- 
ing and evening with a saturated solution of alum in cool water, and 
finally by the application of the following ointment. 

Take of bees-wax, olive-oil and lard, each two ounces, extract of stra- 
monium tannin, and oxide of zinc, of each half an ounce. Melt the bees- 
wax and lard together, to which add the sweet oil, and as they cool, add 
and mix intimately the stramonium tannin and oxide of zinc. A little 
of this may be applied to the tumors morning and evening till their irri- 
tation, pain and soreness subside. 

I believe that by a proper course of treatment, thus judiciously ap- 
plied, many cases of piles may be entirely cured, and the worst cases 
greatly benefitted. If, however, a judicious medical treatment fails in 
producing relief, the tumors may generally be safely removed by the 
ligature, carefully and properly applied. 

SECTION XXXII.— JAUNDICE— {Icterus.) 

By jaundice or icterus, I mean that affection in which there is gene- 
rally yellowness of the skin, eyes, and urines, from the presence of bilous 
matter, caused either by retention or suppression of bile, in consequence 
of some derangement in the secretion of the liver, or obstruction in its 
excretory duct, It will be remembered that the bile is a yellowish fluid 
consisting of a "resinous soda salt, a coloring material, cholesterine and 
mucus," and that it is probably derived from decomposing waste materials 
of the system, and very much of it from decomposing blood-cells. 

Now, as the proximate constituent principles of the bile pre-exist in 
the blood, a failure on the part of the liver to drain it off may produce 
a jaundiced state, in which case we may have jaundice from suppression 
of the bile. But if the liver performs its functions, or separates the bile, 
and yet it fails of reaching the intestine through its excretory duct, there 
is soon a jaundiced condition, either from absorption of retained secreted 
bile, or else from an interruption to its further secretion caused by the 
obstruction, and hence we have jaundice from retention of the bile. 

The normal course of the bile after it is secreted, it will be remem- 



JAUNDICE. 417 

bered, is along the hepatic duct, and ductus communis choledochus to the 
duodenum. Or if it has passed to the gall-bladder, it passes by the cys- 
tic duct, and then along the ductus communis choledochus to the intes- 
tine. 

Now the cystic and hepatic ducts unite to form the common excretory 
duct of the liver and gall-bladder, which common duct is about three 
inches in length, aud empties into the perpendicular portion of the duo- 
denum, passing obliquely between its muscular and mucous coat. The 
hepatic ducts have an external coat of contractile fibrous or muscular 
tissue, and an internal mucous coat which is continuous with that of the 
duodenum. 

Now the calibre of even the common bile duct is very small, and as it 
passes obliquely through the coats of the duodenum, it is liable to become 
clogged or obstructed from various causes, among the most frequent of 
which are biliary concretions coming down from the gall-bladder, thick 
or viscid bile, inflammation or thickening of the duodenal mucous mem- 
brane obstructing its mouth, and finally inflammation or spasm of the 
duct at any point. 

It is easy to see that a failure on the part of the liver to separate from 
the blood the constituent principle of the bile, or an obstruction to its 
free passage along the ducts after it is secreted, will cause to be retained 
in, or else to be reabsorbed into the blood, the bile, or its constituent 
principles, which being carried along in the blood, is finally thrown upon 
the skin, and more or less into nearly every tissue of the body. In con- 
sequence of the presence of the coloring matter of the bile in the blood, 
the skin, the eyes, and urine, have a yellow tinge, and its absence in the 
intestines leaves the stools of a light clay color, as is generally the case, 
and hence too the symptoms of this disease which we will now proceed 
to consider. 

Symptoms. — The absence of bile in the intestines, and its presence in 
the blood, whether from suppression or retention produces languor, loss 
of appetite, indigestion, constipation, a feeling of fullness in the epigas- 
trium, restlessness, nausea, a turbid urine, a slow pulse, and creeping 
chills, which alternate with flushes of heat. 

After a few days itching occurs over the surface of the body, the mouth 
is bitter, the stools are clay-colored, the urine assumes a saffron hue, and 
finally the white of the eyes, and the skin about the neck, lips, and fore- 
head, assume a yellowish color, which speedily extends until the whole 
surface of the body acquires a yellowish hue. At this stage the pulse 
may become full and firm, and slight febrile exacerbations may take place 
in the evening with increased heat of skin, followed by more or less rest- 
lessness during the night. Finally, if the disease continues, the body 
begins to emaciate, the evening febrile exacerbations become more con- 
spicuous, night-sweats ensue, hemorrhages, or dropsical effusions take 
place, respiration becomes oppressed, and unless the disease be arrested, 
a torpid condition may supervene before a fatal termination. 

Anatomical Characters. — The post-mortem examination discovers any 
organic lesion upon which the disease may have depended, and in addi- 
tion to this, as well as in all cases in which no organic lesions appear, 
there is found a yellow tinge of nearly all the tissues of the body, even 
27 



418 DISEASES OF THE DIGESTIVE SYSTEM. 

of the bones. The substance of the brain, however, sometimes remains 
of its natural color. 

Causes. — Among the causes "which operate to produce this disease, by 
causing a suppression of the bile, or a retention of its constituents in the 
blood, are the paludal 'poison, excessive and long continued heat, mas- 
turbation, onanism, and excessive venery, depressing mental emotions, 
and violent anger, or long continued and excessive grief. All these 
causes probably operate by suspending or diminishing the secretion of 
the liver, in consequence of which it fails to strain off from the blood the 
proximate constituent principles of the bile. 

Among the causes that produce jaundice by a retention of the bile, 
or by an interruption to its free passage along its ducts to the intestine, 
are, as we have seen, biliary concretions, spasm of the duct, duodenal 
inflammation, induration of neighboring parts, viscidity of the bile, and 
some other occasional causes. 

In cases in which the jaundice is from suppression of the bile, the dis- 
ease comes on more or less slowly and insidiously, and is attended gene- 
rally with little or no pain, and very slight, if any, febrile exacerbations, 
especially in the early stage of the disease. In cases, however, in which 
the disease is from obstruction of the bile duct, the disease may come on 
more suddenly, and be attended with pain, febrile exacerbations, &c, at 
an early stage of the disease. When biliary concretions pass down and 
close the duct, there is severe pain, and all the symptoms proceed 
rapidly. In cases depending upon spasm of the duct, I have generally 
found more or less spinal irritation, and pain in the back as well as in 
the region of the duct. 

Cases depending upon duodenal irritation or inflammation generally 
come on slowly, and are attended with slight uneasiness and tenderness 
in the duodenum, and more or less colic pains in that region. If, how- 
ever, it arise from scirrhus of the pylorus or duodenum, there is in addi- 
tion great emaciation with general debility. 

In cases in which the disease is produced by a viscid state of the bile, 
the disease may come on slowly, with little or no pain, except perhaps a 
dull heavy feeling in the right hypochondrium. Finally, if pregnancy 
or impacted feces in the colon produce the obstruction, the symptoms are 
usually sufficiently manifest, especially if the cause be pregnancy, and 
long continued constipation is sufficient to suggest that cause when it 
exists. 

Prognosis. — The prognosis in jaundice is generally favorable, except 
in cases depending upon some powerful general depressing agent, and 
those depending upon or complicated with scirrhus or some other organic 
disease of the stomach, pancreas, or other surrounding parts. 

Treatment. — The indications in the treatment of jaundice are to re- 
store the secretion of the liver, if that is suspended or diminished, and to 
overcome any obstruction there may be to the free passage of the bile 
from the liver to the intestine, after it is secreted. 

Now as digestion is always more or less impaired while there is sup- 
pression or retention of the bile, from its absence in the intestines, as 
well as from its presence in the blood, a three grain pill of inspissated ox 
gall may be given after eating, morning, noon and night, in this disease, 



JAUNDICE. 419 

so long as bile is not secreted by, or carried from the liver to the intes- 
tine. This will generally secure a tolerable digestion, or at least favor 
chylification, and thus tend to keep up the strength of the patient, till 
such time as the secretion of sufficient bile may be restored, or any ob- 
struction there may be to its free passage to the intestines be overcome. 

As there is, too, in most cases of jaundice more or less viscidity of 
the bile, or liable to be at least, ten grains of the bi-carbonate of soda 
may be given, in solution, before each meal, for a time, for the purpose 
of thinning it, which it will generally do very effectually. For the pur- 
pose of restoring or improving the secretion of the liver, a blue pill may 
be given at evening, for a time, and followed each morning by a tea- 
spoonful of the sulphate of magnesia, to secure a daily movement of the 
bowels. After having continued the mercurial for a reasonable time, it 
may be suspended, and a teaspoonful of the fluid extract of dandelion, or 
an equivalent dose of the decoction, may be given after each meal, till the 
secretion of the liver is restored. Or in cases of jaundice in which a mer- 
curial is from any cause contra-indicated, a grain or more of podophyllin or 
leptandrin may be given, at evening, instead of the blue pill, and followed 
by the sulphate of magnesia in the morning, if necessary, and this may 
be continued till the function of the liver is restored ; or it may be sus- 
pended, after a time, and the taraxacum continued in its stead, as sug- 
gested above. The warm foot-bath should be used at evening, and the 
patient should be allowed a plain, digestible, and nourishing diet, to be 
taken with regularity, and should take a reasonable amount of exercise, 
and maintain an even cheerful temper of mind. 

With this course of treatment most cases of jaundice, from suppres- 
sion of the bile, may be overcome. But if there is evidence of retention, 
from some obstruction to the free passage of secreted bile to the duode- 
num, other measures, in addition to what I have already suggested, are 
clearly indicated. In cases in which there is evidence of spasm of the 
bile-duct, twenty drops of the tincture of stramonium, or ten drops of 
the fluid extract, may be given, four times per day ; and if there is 
spinal irritation, as I have generally found in such cases, cups should be 
applied on the right side of the spine, opposite the liver, and two or 
three ounces of blood taken. Finally, in all cases in which there is 
evidence of inflammation or congestion of the bile-duct or duodenum, in 
addition to the treatment I have already suggested, cups should be 
applied at first, and later blisters, if necessary, over the bile-duct and 
duodenum. 

The indications then, in cases of jaundice from suppression merely, 
may generally be fulfilled with the blue pill, podophyllin, or leptandrin 
at evening, for a time, followed by the sulphate of magnesia in the 
morning, together with the ox-gall and bi-carbonate of soda, as sug- 
gested, and the taraxacum, if necessary. But in case there is retention 
of secreted bile, in addition to the above, stramonium, cupping, blis- 
tering, &c, may be indicated, and should be faithfully and judiciously 
applied, as I have suggested. 



CHAPTER IX. 
DISEASES OF THE RESPIRATORY SYSTEM. 



SECTION I.— AUSCULTATION AND PERCUSSION. 

By auscultation and percussion I mean, to include here physical ex- 
ploration of the chest. Before proceeding to the consideration of the 
diseases of the respiratory system, I propose to consider in this section, 
under the head of auscultation and percussion, the principles of physical 
diagnosis, embracing inspection, palpation, percussion, auscultation, men- 
suration and succussion, so far as they are applicable to diseases of the 
respiratory organs; leaving so much of this subject as is applicable to 
the heart, for consideration in the following chapter, in which I shall 
take up the diseases of the circulatory system. 

Now, in order to appreciate this subject, it is necessary to bear in 
mind the anatomy and physiology of the respiratory organs, as well as 
to understand the normal sounds produced by respiration, by the voice, 
by percussion, &c, in order to be able to discover any deviation from the 
normal standard; and thus to appreciate the signs of internal disease, 
indicated by abnormal sounds. 

In diseases of the respiratory organs requiring physical exploration of 
the chest, the patient should, if convenient, be placed in the sitting 
posture, and the clothing should be removed, as far as may be consistent, 
and then the anatomy and physiology of the parts being kept in mind, it 
is also proper to understand the regions into which the chest, and even 
the whole body is usually divided. And, as the different regions of the 
chest and abdomen are liable to be called up, in our minds at least, at 
almost every step of our proceedings, it may be proper for us to refer to 
the boundaries of these regions before we proceed to a consideration of 
inspection, percussion, auscultation, mensuration, succussion, $c. 

Now, the chest and abdomen may conveniently be divided, as is cus- 
tomary, into regions in the following manner : Let three vertical lines 
be drawn, one on each side of the sturnum, and one along the whole 
length of the spine, and also a vertical line from the scapular extremity 
of the clavicle on each side to the spinous process of the pubis, as well 
as one from the posterior boundary of each axilla perpendicular to the 
crest of the ileum. Let now five transverse lines encircle the body ; the 
first, on a level with the clavicles; the second, on a level with the junc- 
tion of the cartilage of the fourth rib with the sternum ; the third, on a 
level with the extremity of the xiphoid cartilage; the fourth, on a level 
with the end of the last rib ; and the fifth, on a level with the spinous 
processes of the ossa ilii. 

Now, the regions bounded by these vertical and transverse lines are as 
follow: Above the first transverse line are the acrominal regions; be- 



AUSCULTATION AND PERCUSSION. 421 

tween the first and second transverse lines, in the middle, in front is 
the superior sturnal region, and on each side laterally, the inferior clavi- 
cular, the axillary, and the scapular regions; between the second and 
third transverse lines, in the middle and front, is the inferior sternal 
region, and on each side, the mammary, lateral and infra scapular 
regions; between the third and fourth transverse lines there is in front 
the epigastric, and on each side the hypochondriac and dorsal regions; 
and finally, between the fourth and fifth transverse lines we have in 
front the umbilical, and on each side, laterally, the iliac and lumbar 
regions. Now, bearing these regions thus bounded in mind, we are pre- 
pared, with our knowledge of the anatomy and physiology of the parts, 
to proceed in the examination ; and first by inspection, as I have already 
suggested. 

By inspection, we discover the size, and general form of the chest, as 
well as the working of the chest, its degree of expansion, &c. It is also 
proper to note the action of the intercostal, and abdominal muscles; as 
very important indications of disease may be furnished by the intercostal, 
or abdominal character of the respiration. Having thus noted the indi- 
cations furnished by inspection, palpation may next be resorted to; and 
this may confirm the hints furnished by inspection. 

Palpation, by laying the flat hands on corresponding parts of the two 
sides of the chest, may be a great help, in discovering the difference in 
the motion of the two sides, if any exist. This method of palpation 
often also does more, by detecting any roughness there may chance to oe 
from pleuritic, or pulmonary disease. 

Palpation is also of service in detecting chronic pleuritis. For by 
pressing the ends of the fingers along the intercostal spaces, tenderness 
is often detected ; thus bringing to light, a morbid condition, which might 
not be detected by any other symptom, at least in its early stages. This 
method of palpation, is also of service in exploring other parts of the 
body, as well as that of laying the palm of one hand on a part to be ex- 
amined, and gently tapping at an indefinite distance, so as to elicit a 
sense of fluctuation, if there is fluid within. By this method, we may 
sometimes detect the existence of fluid in the pericardium, as well as in 
the abdominal cavity. 

Having proceeded thus far in our examination, and having availed our- 
selves of the signs furnished by inspection and palpation, percussion, or 
striking the parietes of the chest in such a manner, as to elicit the amount 
of resonance, or dullness of the parts beneath, is the next step in the 
order of our inquiry. 

Percussion may be immediate, in w T hich case the hand, and generally 
the end of the fingers, falls immediately upon the chest, or part to be 
examined. Or, it may be mediate, in which case the fingers of the 
other hand, or some other substance intervenes. 

Immediate percussion may be resorted to in very lean subjects; or in 
cases in which the application of a pleximeter is impossible, or incon- 
venient. And it may be very conveniently performed, by the first three 
fingers ; the ends being brought together, and the fingers slightly flexed. 
In fat subjects, and in most cases in which a pleximeter can be conveni- 
ently applied, mediate percussion is preferable, and it may be most 



422 DISEASES OF THE RESPIRATORY SYSTEM. 

conveniently performed, by using the three first fingers of one hand, as 
the plessor, or instrument for striking, and the middle finger of the other 
hand, as the pleximeter. 

Now, in order to appreciate the signs, furnished by percussion, in dis- 
ease, it is necessary to understand the natural sounds, which are elicited 
in different parts of the chest in a state of health, that the morbid sounds 
may be compared with the natural; and thus the indication which they 
furnish of internal disease, be clearly appreciated. It is well then, to 
bear in mind that tympanitic sounds are elicited in health, in the lower 
part of the mammary, left lateral, and infra-scapular regions. The su- 
perior sternal, axillary, and upper part of the infra-scapular regions, are 
very resonant. The subclavian, the upper part of the mammary, the 
lateral and interscapular regions, are resonant. The acrominal, lower 
part of the right mammary, lateral, and infra-scapular regions, are im- 
perfectly resonant. Finally, the inferior sternal, the inner edge of the left 
mammary, and the scapular regions, produce dull sounds on percussion. 

It is only necessary to remember the position of the heart, liver, and 
other internal parts as well as the intervening parietes, in order to un- 
derstand the rational of the variety of resonance elicited by percussion 
in different parts of the chest, in a state of health. 

The indications of internal diseases furnished by percussion are very 
numerous, and the variety of diseases of the respiratory organs in which 
it affords important signs are so numerous, that I will mention the most 
important of them, and the peculiarities of each. 

In simple bronchitis, the resonance on percussion is nearly or quite na- 
tural, at least in the early stage of the disease. But if there is a copious 
secretion of mucus in the bronchial tubes, a slight dullness may be noticed 
in some cases. 

In pneumonia, there is usually a dull sound on percussion, and espe- 
cially is this the case, if the inflammation has passed on to hepatization 
as is too often the case. 

In phthisis, there is generally a dullness on percussion over the upper 
part of the lungs during the early stages. But as a cavity forms, the 
sounds gradually become resonant, and finally in the latter stages even 
tympanitic. 

In congestion of the lungs, there is generally more or less dullness on 
percussion, and the same is also true in oedema, especially in the most 
depending part. 

In malignant diseases of the lungs, such as scirrhus, if it be extensive 
there is dullness on percussion over the indurated part. But in emphy- 
sema there is generally increased resonance in proportion to the increased 
amount of air the lungs contain. 

In hydroihorax as the fluid accumulates and fills the chest, compressing 
the lung, dullness attends, being discoverable first in the most depending 
part of the chest, but extending gradually as the effusion increases. 

In malignant disease of the pleura, as in that of the lungs, the pul- 
monary tissue is compressed, being pushed aside, and dullness on per- 
cussion follows as a consequence. 

In pneumothorax, percussion elicits a resonant, or tympanitic sound. 
But if air and a fluid exist in the same serous sac, there is dullness 



AUSCULTATION AND PERCUSSION. 423 

in one part, and tympanitic resonance in another. If, now the patient 
under examination be suffering from either of the diseases enumerated 
above, an important clue to the disease may thus be had by percussion, 
in addition to the signs furnished by inspection and palpation. 

The next step in the order of our examination is auscultation, or lis- 
tening to the sounds arising from the exercise of the functions of respira- 
tion, and comparing those emanating from diseased organs, with those 
ascertained by previous examination, or experience to exist in the healthy 
condition of the organs. 

Auscultation, as well as percussion, may be either immediate or 
mediate. 

It is immediate when the ear is placed directly on the part, entirely 
bare, or covered only by a thin cloth, the vibrations being conducted di- 
rectly to the ear. 

It is mediate when between the ear and the parietes a body is inter- 
posed, which conducts the vibrations from one to the other. The steth- 
oscope, or instrument so interposed, is only a convenience in particular 
cases, or in examining particular parts of the chest, as immediate aus- 
cultation is, according to my experience, the most reliable. 

In immediate auscultation the ear should be applied to different parts 
of the chest, in such a way that the ear may participate in the vibra- 
tions of the solid parietes upon which it is placed. 

When the stethoscope is used, it should be pressed upon the parietes 
of the chest, its cylinder being always at right angles to the surface with 
which it is applied. The ear, too, should be evenly adjusted to the flat 
end of the other extremity, if the old style of stethoscope is used, and 
so firmly pressed as to make the parietes of the chest, the stethoscope 
and the ear one continuous vibrating body. 

It is necessary that the auscultator should understand the natural res- 
piratory sounds, in the larynx, trachea, bronchial tubes and lungs, as 
well as the natural sounds of the voice in these parts. For it is by com- 
paring the morbid with the healthy sounds, that auscultation becomes an 
important means of diagnosis. In examining the patient by auscultation 
it is generally best to notice first the respiratory sound, and then to no- 
tice the change which takes place in the voice and cough. 

If from inflammation, congestion, or thickening of the larynx or tra- 
chea, the air be obstructed in its passage, a whistling or crowing sound 
is produced by the act of respiration, and it is loud or slight according 
to the amount of the obstruction. 

The respiration in the bronchial tubes in health is hardly audible, but 
if there be congestion of their mucous membrane, the tubes become 
thickened, as in the first stages of bronchitis, and a " sonorous rattle or 
rouchus" is heard, on applying the ear to the chest. If, however, from 
any cause the smaller bronchial tubes are constricted, as sometimes hap- 
pens in bronchitis, or in spasmodic contraction of the tubes, we have a 
hissing or squeaking noise, which constitutes " the sibilating rattle or 
rouchus." 

In emphysema of the lungs there is generally a short inspiration, 
" and a loud, protracted, and wheezing expiration." This I believe is 
true whether the emphysema be interlobular, consisting in infiltration of 



424 DISEASES OF THE RESPIRATORY SYSTEM. 

air into the areolar texture, or vesicular, depending merely upon dilata- 
tion of the air-cells. 

In the early stages of phthisis, when the tubercles occupy the superior 
portion of the lungs, the inspiratory murmur assumes a harsh, hoarse 
character, and the intensity of the expiratory murmur is increased, and 
its duration prolonged. Later in phthisis, when quite a portion of the 
lung becomes filled with tubercles, and its smaller tubes consequently ob- 
structed, there is the sound of air passing through the larger tubes of the 
part, constituting the "tubular breathing" or bronchial respiration. 
When, however, a bronchial tube becomes very much enlarged, or a 
cavity is formed in the substance of the lung, a sonorous or hissing noise 
takes the place of the bronchial respiration, and this constitutes the 
" amphoric breathiny," resembling the sound produced by blowing into 
a large-mouthed bottle. 

When air passes through a bronchial tube into a cavity, a sound is 
produced like that of blowing through a tube into a glass vase, the sides 
of which vibrate slightly, and this constitutes the metallic respiration. 
Sometimes there is a distinct tinkling, like the bursting of air through 
the secretion of the tube into the cavity, and this constitutes the " me- 
tallic tinkling." 

In scirrhus of the lung, one marked case of which has fallen under 
my observation, all the respiratory sounds gradually change, and finally 
cease in the part, except so much as is conducted by the consolidated 
mass from other healthy or less diseased parts of the lung. 

When a tumor growing from the posterior walls of the chest internally, 
presses against the lung in or about its middle, there is a lengthened in- 
spiration, and two or three distinct interruptions in each expiration, and 
this I have named the interrupted expiratory sound.* 

Such I believe are the chief, or most important dry sounds connected 
with respiration, liable to be detected by auscultation. But it must be 
remembered that they are frequently connected with other and moist 
sounds which often materially modify both the dry and moist sounds. 

Besides the dry sounds produced by diseases of the air passages and 
lungs, certain dry sounds may be discovered by auscultation resulting 
from diseases of the pleura, the most important of which are the follow- 
ing. When in inflammation of the pleura, there is thrown out on its 
surface an albuminous layer, however, thin, the surface of the pleura be- 
comes rough, and the friction produces vibrations and a friction sound, 
which has been called the "pleuritic rubbing." When, however, the 
pleuritic effusion becomes dry as it often does, the friction of the pul- 
monic and costal pleura may produce a harsh grating sound like the 
rubbing together of rough pieces of cloth or wood, or the sound may be 
of a creaking or squeaking character, similar to that produced by the 
bending of stiff leather. 

When at other times the pulmonary and costal pleura become so rough 
that they will not readily glide over each other, as sometimes happens in 
the early stages of phthisis, from inflammation or from tuberculous 
deposits, a rustling noise is produced which has been compared to that 

* I discovered this sound in 1854, for an account of which see Buffalo Medical Journal 
for March, 1855, vol. x. page 587. 



AUSCULTATION AND PERCUSSION. 425 

produced by squeezing together soft gauze paper, and this has been 
called the " pulmonary rustling" but I think may more properly be 
termed the pleuritic rustling. 

When effusion takes place into the cavity of the pleura, in quantity 
sufficient to compress the adjoining lung, the air-cells become partially 
closed up, and the air passing along the larger bronchial tubes produces 
the tubular breathing. 

In cases in which there is a communication between one or more bron- 
chial tubes and the cavity of the pleura, from any cause, more or less air 
passes into the serous sac, producing the " fistulous breathing" the " am- 
phoric respiration" and the " metallic resonance" to which reference 
has been made in describing the dry lung sounds. 

When the air in passing into the pleura sac, enters by a small opening, 
the natural secretion of the tubes by interrupting and bursting into the 
sac, produces in some cases the metallic tinkling before described. 

All the moist sounds in diseases of the respiratory organs, arise from 
the passage of air through fluid or from the admixture of air with fluid. 
They may occur during inspiration or expiration, and may be situated or 
produced in the larger or smaller bronchial tubes, from the presence of 
mucus, blood, serum or pus with more or less air. 

The moist sounds vary according to the size of the bubbles which pro- 
duce them, or what amounts to the same thing, according to the caliber 
of the tube through which the air passes, in which the bubbles are formed. 
Thus the bubbles are larger in the trachea than in the bronchial tubes, 
and also in the larger than in the smaller bronchial tubes. The different 
extent of space then in which the bubbles are formed and burst, produces 
a corresponding difference in the result in resonance. The term rhouchus 
applies more properly I think to the dry sounds, while the term rale or 
rattle expresses more fully the moist, I shall therefore generally thus 
use them. * 

When the bubbles are large, or their resonance full, as they occur in 
the trachea, or in a cavity, the resonance is called the " tracheal rattles 
or gurgling." But when they are smaller, " as in the bronchial tubes of 
the first and second size," the sound is called the "mucous or bronchial 
rales or rattles." And when they are still smaller, as in the finer divi- 
sions of the bronchial tubes, the sound is termed the " sub-crepitant 
rattles." Finally, when the small bubbles are in the air-cells themselves, 
or in the capillary branches in immediate connection with them, the 
sound has been called the " crepitant rales or rattles." 

Now the bubbles, the bursting of which produce the tracheal rattles, 
may be, as suggested by Dr. Hughs, the size of a bean, those producing 
the mucous rattle the size of a pea, those producing the sub-crepitant the 
size of a mustard seed, and finally those producing the crepitant the size 
of a poppy seed, and they are produced in the following manner. When 
either with or without contraction of the larynx or trachea, a fluid is 
present in the larynx or trachea, the air in the inspiration and expira- 
tion is obstructed by the fluid, and bubbles are formed, the bursting of 
which produces a gurgling noise, or the tracheal rattle. The presence 
of blood or mucus in the bronchial tubes of the first or second size, pro- 
duces by inspiration and expiration, bubbles of a smaller size than these 



426 DISEASES OF THE RESPIRATORY SYSTEM. 

in the larynx or trachea, and hence the mucous rattle. When the smaller 
bronchial tubes are principally affected, the fluid and air produce bubbles 
less than those producing the mucous rattle, and larger than those which 
produce the crepitant, and hence the muco-crepitant or sub-crepitant 
rattle is produced. And finally, in cases in which the air-cells are filled 
with serum as in oedema of the lung, with blood as in apoplexy of the 
lung, or with a thick viscid mucus, as in inflammation of the lung, a very 
fine sound is produced by the intermingling of the inspired air with 
the fluid so situated, and thus the crepitant rattle is produced. 

When inflammation of the lung passes on to disorganization of their 
substance, the air in passing into the disorganized mass of fluid matter 
makes a sharp, shrill, loud, muco-crepitant rattle. But as the lung con- 
tinues to break down, the bubbles become larger, till at last a cavity is 
formed, and amphoric breathing and gurgling take the place of other 
sounds. The gurgling rattle is also produced by enlargement of the 
bronchial tubes, or when any considerable cavities are formed in the 
lungs from any cause. 

In the early stages of phthisis, the first moist sound is generally a fine 
sub-crepitant rale, caused by bubbles in the small bronchial tubes, the re- 
sult of inflammation from the presence of tubercles. This sound may be 
limited to a small space at first, but as the disease progresses it may 
become quite general. 

In the latter stages of phthisis, the sub-crepitant, the loud mucous 
rale, and the gurgling usually succeed each other, and are variously 
combined in the destructive progress of the disease. And it should be 
remembered that cavities may exist so high in the lungs, that to be de- 
tected the ear or stethoscope should be placed on the neck, above the 
clavicle. 

When one or more bronchial tubes communicate with a cavity, or a 
collection of matter in the pleura, we have the fistulous or amphoric 
respiration, accompanied sometimes with the metallic tinkling, and fre- 
quently with the sonorous mucous rale, called gurgling. The metallic 
tinkling arises in cases in which the bronchial tubes communicate with 
the cavity of the pleura, in which there is a fluid and air, and is pro- 
duced during inspiration. 

Having listened attentively to the respiratory sounds, the sounds of the 
voice and cough should also be noticed, as they furnish important signs in 
diseases of the lungs and pleura. The changes produced in the auscula- 
tion of the voice resemble those that occur in breathing, that is, what- 
ever renders the conducting powers of the thoracic organs greater, will 
increase the resonance of the voice, as it increases the respiratory sounds. 

In disease of the larynx the voice becomes altered, and there is little 
difficulty in distinguishing the seat of the disease, as well as its nature, to 
some extent, by the sounds of the voice. 

In ordinary bronchitis, the voice sounds are not materially changed, 
unless the lung becomes congested with blood, in which case its conduct- 
ing power is increased, and the voice and cough become louder in the 
parts affected than in other parts of the chest, the base of the lungs 
generally exhibiting most change in such cases. When the bronchial 
tubes are enlarged, and the surrounding portion of the lung is indurated, 



AUSCULTATION AND PERCUSSION. 427 

the voice is increased in resonance, which increase amounts to broncho- 
phony or pectoriloquy, or a sound nearly as distinct as if the lips of the 
speaker were placed at the ear of the listener. 

In simple emphysema, the density of the lung is lessened, and conse- 
quently the resonance of the voice heard through the parietes of the 
chest is also lessened. 

In pneumonia, the density of the lung is increased, the voice being 
more easily transmitted, and hence bronchophony is generally heard in 
such cases. But if the larger bronchial tubes, passing through the dis- 
eased part become closed, the sound of the voice may be more indistinct 
than in health. In congestion of the lungs they become more firm, and 
in consequence a better conductor of sound, hence the increased reson- 
ance of the voice in such cases, amounting sometimes to bronchophony. 

In scirrhus and other malignant diseases of the lung, if the deposit 
does not close the bronchial tubes, there is increased resonance of the 
voice, depending upon the degree of induration, and the permeation of 
the bronchial tubes. But if the bronchial tubes become involved in the 
induration, the sounds of the voice may be lessened, or even lost over 
the part. 

In the early stages of phthisis, there is usually a slight increase in the 
sounds of the voice, in the upper part of the chest, which is not very 
marked at first. But as the disease progresses, and cavities form, and 
the surrounding lung becomes indurated, the sound of the voice is mate- 
rially increased, amounting to bronchophony or pectoriloquy. These 
observations in relation to the sounds of the voice, apply also to the 
sounds produced by the cough, only the sounds of the voice may some- 
times be distinct, while the sounds of the cough are inaudible. 

When a small amount of fluid is present in the pleura, the spongy 
tissue of the lung is compressed, and the effused fluid as well as com- 
pressed lung being good conductors of sound, the resonance of the voice 
is conveyed more distinctly than in a natural condition of the chest. But 
it more frequently happens in such cases that the voice becomes not only 
increased, but it assumes a peculiar "bleating sound," and from its re- 
semblance to the bleating of the goat, has been called " segophony." 

When a communication exists between the bronchial tubes and the 
cavity of the pleura, and this cavity contains air, both the voice and 
cough possess that same " ringing metallic resonance," which we have 
already noticed in the breathing of pneumothorax. And though it gene- 
rally accompanies both the voice and cough, in some cases the cough 
possesses this metallic character, «hile the voice does not. Such then 
are the sounds liable to be detected by auscultation of the respiratory 
organs, and such also are the signs which they afford of the nature and 
extent of diseases of these organs. 

Having thus examined our patient by inspection, palpation, percus- 
sion, and auscultation, and gathered from the signs which they afford 
rational evidence of the nature and extent of the disease within, there 
only remains to be gathered the additional evidence afforded, in some 
cases, by mensuration and succussion, and our physical exploration in 
the case will be completed. 

I believe that in a large majority of cases mensuration need not be 



428 DISEASES OF THE RESPIRATORY SYSTEM. 

resorted to, and further, that it should never be relied upon as affording 
positive evidence of any particular morbid condition of internal parts. 
In some rare cases, however, it may be desirable to ascertain the capa- 
city of the thorax, or to note the quantity of air respired in a given 
time, or taken in at a single inspiration, which may be done by breathing 
into a bell-glass, filled with water, and inverted over a basin containing 
water. Or the amount of expired air may be measured by instruments 
properly adjusted ; one of the best of which is that invented by Mr. 
Huchinson, and which is called the "spirometer.*" 

Mensuration may also be of service in ascertaining the presence of 
fluid in the pleural sac, as well as of malignant or other morbid growths, 
distending or enlarging one side of the chest. This may readily be 
done by a tape passsed around the chest, noting carefully the difference 
in the measurement of the two sides, from the spine to the middle of the 
sternum. 

Should it be desirable to ascertain the expansibility of the two sides 
of the chest, it may be conveniently done by a tape passed round the 
chest, the two ends of which meet at a mark in the centre of the sternum. 
The finger of an assistant may be placed on the tape at the point where 
it passes over the spine, and the ends of the tape being held loose for- 
ward, at the centre of the sternum, each inspiration will show the expan- 
sibility of the chest by the distance to which the ends of the tape recede 
from the line at the middle of the sternum. And by noting the-differ- 
ence in the retraction of the two ends of the tape, the comparative expan- 
sibility of the two sides may be ascertained, as suggested by Dr. Hughes. 
Or, if at hand, the " stethometer" of Dr. Quain, or the " chest measurer" 
of Dr. Sibson, may be convenient in the mensuration of the chest while 
in motion ; the former of which indicates the change in the circumfer- 
ence, and the latter the change of diameter, in the respiratory move- 
ments, f 

Finally, having proceeded in the examination of our patient by inspec- 
tion, palpation, percussion, auscultation, and mensuration, if necessary, 
the additional method by succussion only remains, in certain cases, in 
which the presence of air and a fluid is suspected in the cavity of the 
pleura, or a very large cavity in the lungs. 

The examination by succussion may be conveniently done, when re- 
quired, by shaking the patient by the shoulders, not too violently, and 
then applying the ear to the chest, at the suspected point, when if there 
is a fluid, with air, in the pleura, or a very large cavity in the lung, a 
sound may be heard, similar to that produced by shaking a cask which 
contains air and a fluid. Thus then have we completed the several steps 
in the physical exploration of the chest, the principles of which may 
guide us in the diagnosis of diseases of the respiratory system. 

SECTION II.— PLEUKITIS— [Pleurisy.) 

Having taken a glance at auscultation and percussion in the preceding 
section, I propose in the present to consider pleuritis or inflammation of 

* For a description of this instrument, see note in Wood's Practice of Medicine, vol. i., 
p. 805. 

f For a description of these instruments, see note in Wood's Practice, vol. i., p. 805 ; 
or Bennett's Clinical Lectures, pp. 32, 33. 






PLEURITIS. 429 

the pleura. But as we are about to take up the diseases of the respira- 
tory system in the present chapter, let us remember that the respiratory 
organs, embracing the larynx, trachea, bronchi, lungs and pleurae ; situ- 
ated, as they are, mainly within the walls of the thorax, require to be 
thoroughly studied and perfectly understood, in order that the symptoms 
developed in their diseases may be fully appreciated. 

It should be remembered that the lungs perform an important func- 
tion, and that the various parts of the respiratory system must be in a 
good condition, to secure the perfect performance of this function. In 
fact, the respiratory system may be regarded as the lamp of life; the nasal 
fossae, larynx, trachea, bronchi and air-cells being so constituted as to 
admit oxygen, and carry off carbonic acid, while the pulmonary arteries 
and veins conduct the venous blood to, and the arterial blood from the 
minute air-cells, where the oxygen is received and the carbonic acid 
given off. 

Now this process, by which the blood parts with its carbon by way 
of combustion, supplying vital heat, requires the respiratory movement ; 
and hence, in part, the necessity of the pleurae to enable the lungs to 
glide easily against the walls of the thorax in this perpetual motion, 
which the wants of the system imperatively demand. This, then, brings 
us to the consideration of the pleurae, which, it will be remembered, are 
two serous membranes which line each side of the chest and are reflected 
upon each lung. Each pleura is a shut sac, and from the junction of the 
two, the three mediastina are formed: the anterior, the middle, and 
posterior. The two pleurae forming the mediastinum, however, are not 
in contact, there being a space between them, containing all the viscera 
of the chest except the lungs. 

The anterior mediastinum contains the remains of the thymus gland ; the 
middle, the heart, ascending aorta, superior vena cava, the bifurcation of 
the trachea, the phrenic nerve and the pulmonary arteries and veins, while 
the posterior contains the descending aorta, the azygos veins, the thoracic 
duct, the oesophagus and the pneumo-gastric and great splauchnic nerves. 

The pleura covers the diaphragm and that portion of the membrane 
which lines the parietes of the chest is called the costal pleura, while 
that which covers the lung is called the pulmonary. The costal and 
pulmonary portion of the pleura, as well as that covering the diaphragm, 
are exposed to constant friction by the respiratory movements ; which, 
however, in a healthy state of the membrane produces no uneasiness, or 
audible sound. The pleura, thus situated and constituted, is liable, from 
various imprudences, to become inflamed in any or all its parts, the 
symptoms of which we will now proceed to consider. 

Symptoms. — The symptoms developed in inflammation of the pleura 
are just what we should expect would arise from inflammation of a serous 
membrane thus situated. 

There may be a slight feeling of indisposition preceding the attack, 
but often, the first symptom noticed is a chill, followed by febrile reaction 
and attended with violent pain generally in one side of the chest. The 
pain is greatly increased by a full inspiration, or by coughing, in conse- 
quence of which, the respiration is short and the cough stifled as much 
as possible. The cough is of a short, hacking, dry character, and is in- 



430 DISEASES OF THE RESPIRATORY SYSTEM. 

creased as well as the pain, by lying on the affected side; in consequence 
of which, the patient is found, at first, lying on the well side. The pulse 
is hard, full, vigorous and frequent ; the tongue is covered with a thick, 
white fur; the skin is hot and dry; and the urine is of a deep red color 
and small in quantity. 

The breathing is quick, short, and difficult, and is performed mainly by 
the action of the diaphragm, and abdominal muscles ; the motion of the 
chest being restrained, as much as possible, in consequence of the severe 
pain, which the respiratory movement produces. 

Such are the symptoms which first present themselves. But if the 
chest be inspected carefully, its respiratory movements will be found very 
slight, especially of the affected side ; while an examination of the abdo- 
men, will detect the abdominal character of the respiration. 

If now the flat hands be laid upon corresponding parts of the two 
sides of the chest, the diminished respiratory motion of the chest will be 
still more apparent, especially of the affected side, and a roughness, in- 
dicating either a dryness of the pleura, or else an effusion of lymph on 
its surface, may often thus be detected. If now the points of the fingers 
be pressed along the intercostal spaces, in the affected part, tenderness 
will be detected, as far as the inflammation extends, in most cases at least. 

The resonance on percussion, in the early stage, is nearly natural ; but 
if effusion has taken place into the pleura, a dullness is detected in the 
most dependent part of the chest, and this gradually extends, as the ac- 
cumulation increases. 

If now the ear be placed over the seat of the pain and tenderness, the 
stifled respiration will detect a diminution of the natural respiratory 
murmur: and if the inflammation is in its incinient stage, a slight friction 
sound may be heard, caused by a dryness of the pleura; or else by an 
albuminous exudation, rendering its surface slightly rough. If, however, 
the disease has progressed, and the exudation on the surface of the pleura 
has become more dry, a grating sound, like that produced by rubbing 
together rough pieces of cloth, or wood, may be detected; or it may be 
of a creaking or squeaking character, like that produced by bending stiff 
leather. If, however, effusion has taken place, to any considerable ex- 
tent, into the pleura, the respiratory murmur becomes very indistinct; 
but the resonance of the voice, is greatly increased, and may assume the 
peculiar bleating sound, called wgophony. 

Such, I believe, are the ordinary symptoms of simple acute pleurisy; 
but it is liable to variations, in some cases being attended with little or no 
pain ; or it may be complicated with a bilious condition, in which case we 
have, in addition, the symptoms of ordinary bilious fever, with or without 
a typhoid condition. 

Causes. — Sudden exposure to cold, when the body is in a state of pers- 
piration, is probably the most frequent cause of pleurisy; and this is the 
reason why this disease occurs most frequently, at seasons when there are 
marked changes from heat to cold, and when there is a damp and low 
electrical state of the atmosphere. 

Pleurisy also occurs frequently from the metastatis of other affections, 
as rheumatism, gout, erysipelas, &c. Suppression of the menses, from 
exposure to damp or cold, appears sometimes to produce acute pleurisy. 



PLEURITIS. 431 

Pleuritis sometimes also follows capital surgical operations. But the 
disease, in such cases, is apt to come on in a very insidious manner, and 
wants many of the symptoms, which usually attend ordinary acute attacks 
of the disease. 

Finally, the paludal poison, operating through the blood upon the 
brain and nervous system, may so far derange the functions of the body 
as to develop this disease, especially if some accidental exciting cause is 
brought to bear upon the system, such as sudden exposure to cold, 
dampness, &c. Cases of pleurisy depending upon this cause, are very 
apt to be attended with a typhoid condition of the system, the inflam- 
mation being generally, in such cases, of a passive character. 

Anatomical Characters. — On dissection, the pleura is generally found 
red, or filled with small, irregular, red specks. And there is extrava- 
sation on the inner surface of the pleura in nearly all fatal cases of this 
disease, which accounts mainly for the friction sounds which attend this 
affection. The matter thus thrown out by the vessels of the inflamed 
pleura, may be coagulable lymph imperfectly organized, or a pseudo- 
membranous substance may be found adhering to the pleura, and form- 
ing adhesions, in some cases, between the pulmonary and castal pleura. 

In some cases, pus is found in the pleural sac, and very often more 
or less serum, sometimes filling the cavity of the pleura. 

Other morbid appearances may be presented, but the preceding are, 
I believe, by far the most frequent. 

Diagnosis. — Pneumonia and pleurodynia are the affections with which 
pleuritis is most liable to be confounded, from each of which it may be 
distinguished by attention to the following diagnostic symptoms. 

In pleurisy, the patient lies at first on the well side, while in pneu- 
monia, he generally lies on the affected side. 

In pneumonia there may be a dark livid appearance of the counten- 
ance, and considerable cough, with a viscid, rusty expectoration, while 
in pleurisy the face may have a vivid flush, and the cough is short and 
dry, with only a limited glairy, colorless sputa. Finally, the want of 
dullness on percussion in the early stages of pleurisy, as well as the 
absence of the crepitant rale, both of which are present in pneumonia, 
serve to render the distinction between pleurisy and pneumonia clear 
and certain. 

From pleurodynia, pleurisy may be distinguished by the pain being 
more continuous, by its being increased by lying on the affected side, 
and by the more decided febrile symptoms of the inflammatory affection. 
To distinguish bilious from simple pleurisy, it is only necessary to take 
into account the locality, the prevailing epidemic and the endemic influ- 
ences, and to notice carefully the general bilious symptoms which attend 
such cases. 

Prognosis. — Simple acute or chronic pleuritis is generally not a very 
dangerous affection, in persons of good constitution. If, however, the 
disease occurs in debilitated subjects, and from a debilitating miasmatic 
agent or influence, it may assume a typhus or malignant character. 

Treatment.— When the patient attacked with pleurisy is of a strono- 
constitution, and the inflammation is of an active character, general 
bleeding may be necessary at the commencement, and should not be 
omitted. 



432 DISEASES OF THE RESPIRATORY SYSTEM. 

After general bleeding, when it is necessary, and in all cases in -which 
it is not necessary, cups should be applied along the spine, on the 
affected side, and also over the inflamed part, and from four to six 
ounces of blood taken at first, and then it may be repeated in a few 
hours, if necessary. 

The warm foot-bath should be used, and a cathartic of calomel or 
podophyllin should be administered in castor oil, and the oil repeated if 
necessary, every four or six hours, and with each dose, at least thirty 
drops of laudanum, or the same quantity of the fluid extract of opium 
should be given. 

After the operation of the cathartic, one-sixth of a grain of tartar 
emetic may be given, with twenty drops of laudanum, or fluid extract of 
opium every four hours. And if the inflammation has not been subdued 
by the treatment thus far, a large blister should be applied to the affected 
part, and kept sore till the inflammation is subdued. In obstinate cases 
in which the inflammation does not yield to these measures, calomel 
should be administered in two grain doses, with four grains of Dover's 
powder every four hours, till an impression is produced on the disease, 
or the gums become sore when the calomel should be discontinued, and 
the Dover's continued if necessary every six hours. If at this period, 
there is evidence of effusion into the pleura, as the calomel is discontinued, 
five grains of the iodide of potassium may be given every six hours, alter- 
nating with the Dover's powder, and continued till the pleuritic effusion 
is removed. 

During the early stages of pleurisy, crust coffee, with a little milk 
should be allowed. But if the disease passes on and becomes chronic, 
a plain, digestible, and moderately nourishing diet may be allowed. In 
most cases of simple pleurisy, if proper treatment be early applied, the 
disease may be arrested in forty-eight hours, and it is generally, I be- 
lieve from neglect or mal-treatment, that the disease becomes chronic, 
and perplexing complications arise. 

In bilious pleurisy, in which there is generally more or less gastric irri- 
tation, and a typhoid tendency, the general bleeding and antimony should 
be omitted, and a blister should be applied to the epigastrium. The other 
treatment may be nearly the same, only after the operation of the cathar- 
tic, two or three grains of the sulphate of quinine should be given with 
Dover's powder, and calomel, if necessary, and continued till the febrile 
and inflammatory symptoms subside. The patient too, in such cases may 
be allowed from the first, crust coffee, one-half milk, and later, broths, a 
poached egg, toast, and gradually other plain digestible and nourishing 
varieties of food may be allowed. 

SECTION III.— PNEUMONIA— {Pneumonitis.) 

By pneumonia or pneumonitis, I mean inflammation of the substance 
of the lungs, which consists, it will be remembered of the ramification of 
the bronchial tubes, the pulmonary arteries and veins, the bronchial ar- 
teries and veins, the lymphatics and nerves, and a fine connecting areolar 
tissue. 

The lungs it will be remembered, fill exactly the two cavities of the 






PNEUMONIA. 433 

thorax, being connected at their root superiorly, and separated below by 
the mediastinum and heart, the right being divided into three, and the 
left into two unequal lobes. But in order to appreciate the symptoms 
which are developed in inflammation of the lungs, it is necessary to un- 
derstand, and bear in mind the minute anatomy of the pulmonary struc- 
ture, as well as the general physiology of respiration. 

The bronchial tubes which arise from the bifurcation of the trachea, 
on entering the lungs, branch forth very much like a tree, consisting of 
cartilaginous rings, circular muscular fibres, and longitudinal elastic 
tissue, and lined internally with a mucous membrane. Near the termi- 
nation of the bronchial tubes after their calibre become less than -L of an 
inch, they become irregular, and are very properly called " intercellular 
passages,'" being surrounded by air-cells, which communicate freely with 
them. 

These intercellular passages consist of elastic tissue, interspersed with 
muscular fibres, and after bifurcating several times, end in an air-cell, 
which air-cells are from T V to ^Vo of aI * inch in diameter. And as 
each terminal bronchus has probably not less than twenty thousand air- 
cells clustered around it, it has been estimated that the whole number of 
air-cells in the human lungs is not less than six hundred millions. 

Now the pulmonary artery which carries the impure venous blood 
from the right ventricle of the heart to the lungs, dividing, its branches 
terminate in a network of minute capillary vessels, in the parietes of 
the intercellular passage, and air-cells, and then these converge to form 
the pulmonary veins, by which the blood, purified in its passage through 
the capillaries, is returned to the left auricle of the heart. 

Besides the bronchial tubes, the intercellular passages, the air-cells, 
pulmonary arteries, veins and capillaries, the lungs are supplied with 
arteries, branches of the thoracic aorta, which ramify on the parietes of 
the bronchial tubes, their blood being taken up and carried by the bron- 
chial veins to the vena ozygus. The lungs have also lymphatics, which 
commence on the surface, and in their substance, and terminate in the 
bronchial glands. 

The nerves of the lungs it will be remembered, are derived from the 
pneumogastric and sympathetic, forming two plexuses, one on the front 
of the root of the lungs, and the other on the posterior, the anterior 
being composed chiefly of filaments from the cardaic plexus, and the 
posterior principally of branches from the pneumogastric. 

Thus are we reminded that the lungs are composed of an infinite 
number of bronchial tubes, intercellular passages and air-cells. And 
that the pulmonary artery terminating in capillary vessels, forms a net- 
work in the parietes of the intercellular passages and air-cells, and then 
converging from the pulmonary veins, by means of which pulmonary 
artery, capillaries and veins, all the blood passes through the lungs from 
the right ventricle to the left auricle of the heart, the blood parting with 
the carbonic acid, and receiving oxygen during its passage through the 
capillaries in the parietes of the intercellular passages and air-cells. 

The lungs, thus situated and constipated are liable to become inflamed, 
the symptoms of which we will now proceed to consider. 

Symptoms. — The symptoms attending inflammation of the substance 
28 



434 DISEASES OF THE RESPIRATORY SYSTEM. 

of the lungs, are just what might be expected, if we take into account 
the peculiarity of their structure and functions. 

There may be a slight feeling of indisposition for a day or two, but 
frequently a chill more or less marked, is the first symptom which is 
noticed. During the chill there is oppressed breathing in consequence 
of the congested state of the lungs, and often more or less cough. During 
the chill, or as febrile reaction takes place, there is generally an obtuse 
pain felt in the chest, either in the sternal or scapular region, or it may 
occupy any portion of the chest. The cough is dry at first, but soon a 
thick, viscid, lightish matter is thrown up ; and later, a rusty appearing 
matter, from the presence of fine particles of blood, of a less viscid con- 
sistency is raised, but generally in moderate quantities at first. 

As the general fever becomes established, the skin is hot and dry, the 
urine is scanty and high colored, the pulse frequent, full, obstructed and 
laboring but not very hard, and in the latter stages, the pulse may be- 
come weak, obstructed and irregular. 

In violent cases in which the inflammation is extensive, the dyspnoea 
becomes very marked, the veins of the neck become turgid, and the 
countenance acquires a livid aspect from a want of proper decarboniza- 
tion of the blood. If the pleura is not involved in the inflammation, the 
patient generally lies on the affected side, in order to allow the sound 
lung to carry on the respiration in a free and easy manner. But if 
both lungs are involved, the patient lies on his back with his shoulders 
elevated. 

By inspection of the chest, it will be discovered that the affected side 
does not expand during inspiration like the opposite side. 

This may be confirmed by palpation or laying the flat hands on corres- 
ponding parts of each side of the chest, and noticing the difference in 
the motion produced by respiration. 

By percussion of the chest, a dull sound will be produced over the in- 
flamed portion of the lung, in consequence of its increased density ; and 
in order to fully appreciate this dullness, percussion should be made on 
corresponding parts of the well lung. If hepatization has taken place, 
the dullness is very marked over the hepatized portion, amounting to 
flatness. 

Auscultation discovers a want of the natural respiratory murmur, and 
in its stead the crepitant rale, which arises from the passage air through 
the intercellular passages and air-cells, which contain more or less of the 
bloody mucus which is beginning to be expectorated. As hepatization 
takes place, the crepitant rale disappears over the hepatized part, and if 
the larger bronchial tubes remain open, the tubular breathing becomes 
very marked. If, however, inflammation of the lungs passes on to dis- 
organization of their substance, the air in passing into this mass of fluid 
matter makes a loud muco-crepitant rattle. But as the lung continues 
to break down, and a cavity is formed, amphoric breathing and gurgling 
takes the place of other sounds. 

The sounds of the voice and cough are slightly increased in the early 
stages of pneumonia ; and as the density of the inflamed lung increases 
it becomes more marked, amounting to bronchophony, unless the larger 
bronchial tubes become closed, in which case the sounds of the voice and 



PNEUMONIA. 435 

cough may be even more indistinct, than in a healthy state of the lungs. 
In cases of pneumonia which terminate favorably, after tubular breath- 
ing has become marked, there is during convalescence first a return to 
the crepitant rale, and finally to the natural respiratory murmur. 

Anatomical Characters. — Among the morbid structural changes pro- 
duced in the lungs by inflammation, engorgement, red and gray hepatiza- 
tion, gangrene, and abscess, are probably the most frequent ; modifica- 
tions of these conditions depending, I believe, generally upon the exist- 
ence of two or more of these morbid conditions, in the same or different 
parts of the inflamed structure. 

Engorgement, or a congested appearance of the inflamed portion of the 
lung, is sometimes presented ; in which case it is apt to exhibit externally 
a brown color, which forms a strong contrast with the gray color of the 
healthy part. It is of a firmer structure, and heavier than in the healthy 
state, and feels less crepitous under the finger. By pressure, the air- 
cells are found filled with extravasated blood, and when the engorged 
portion of the lung is laid open, with the knife, a frothy, reddish, serous 
fluid runs out, and the structure exhibits a reddish appearance. Simple 
engorgement appears to be the result of the weakest grade of inflamma- 
tion, and may arise from mere sanguineous congestion ; for if portions of 
the engorged lung be pressed till the extravasated fluid is out, and air be 
blown into it, the part becomes elastic and crepitous, and of nearly a 
natural color. 

Hepatization is a morbid condition, sometimes presented, in which the 
diseased lung has the appearance and consistence of liver. In this va- 
riety of structural change the lung is impermeable by air, is deprived of 
its crepitous feel, and sinks in water. 

Red hepatization indicates a higher grade of inflammation than simple 
engorgement. When cut into, a little reddish fluid issues, without ex- 
hibiting a frothy appearance ; the lung having lost its cellular structure 
and assumed a red granular appearance, being readily broken down be- 
tween the fingers and reduced to a pulp. The hepatized lung generally 
appears larger than natural, because it does not collapse in this state. 

Gray hepatization appears to be the result of a more intense inflam- 
mation than the red hepatization. In this morbid condition the pulmo- 
nary structure is granular, condensed, and impermeable by air, as in the 
preceding variety ; but its color is of a grayish or yellowish tinge, and 
when cut into, a yellowish or grayish fluid, of a purulent character, is 
discharged. The pulmonary tissue is softened, and readily converted, 
by slight pressure, to a mere pulp. 

Gangrene may occur from acute inflammation of the lungs, one marked 
case of which has fallen under my observation. In this case, as occurs 
generally in cases of gangrene of the pulmonary structure, there was an 
intolerable fetid breath, especially during fits of coughing, and the mat- 
ter expectorated had an offensive smell. The lungs on examination, in 
such cases, are found converted into a putrid mass, containing fragments 
of pulmonary structure. 

Abscesses sometimes form in the lungs, the result of acute inflamma- 
tion ; the matter which they contain being of a thin purulent character. 
This is not a very frequent termination of pulmonary inflammation, only 



436 DISEASES OF THE RESPIRATORY SYSTEM. 

one well marked case having fallen under my observation. This case 
was a robust young man ; the abscess was opened, nearly a quart of mat- 
ter was discharged at first, I believe, and the patient finally recovered, 
under the care of my friend Dr. Spencer, of TVatertown, N. Y., with 
only a loss of function of that portion of the lung in which the abscess 
occurred. 

Diagnosis. — The diseases with which pneumonia is liable to be con- 
founded are oedema, certain conditions in phthisis, pleurisy, and bron- 
chitis. (Edema and phthisis may generally be distinguished, however, 
by the history of the case, together with the symptoms which are de- 
veloped, without any considerable difficulty. 

From pleurisy pneumonia may be distinguished by the following differ- 
ences. In pneumonia the patient lies on the affected side, while in pleu- 
risy he generally lies on the well side. In pneumonia there is a dull 
pain, with a viscid rusty expectoration, while in pleurisy there is an acute 
pain, and little or no expectoration. The countenance in pneumonia may 
have a livid appearance, while in pleurisy no such symptom attends. 
In pneumonia percussion produces a dull sound, and there is absence of 
the natural respiratory murmur, and in its stead the crepitant rale, while 
in pleurisy there is early little or no dullness on percussion, and only a 
diminished respiratory murmur, with the friction sound, or pleuretic 
rubbing. 

From bronchitis, pneumonia may be distinguished by the livid counte- 
nance, the pain, the character of the febrile excitement, the crepitant 
rale, and by the absence of the sibilant ronchus, mucous and subcrepi- 
tant rale, which so generally attend inflammation of the mucous mem- 
brane of the smaller bronchial tubes. 

Prognosis. — The prognosis in simple uncomplicated pneumonia is 
generally favorable, and especially is it so if there is a tolerable free ex- 
pectoration of the rusty sputa early in the disease, and later an increased 
flow of urine with gentle perspiration. TVhen, on the other hand, the 
pain in the chest increases, and is attended with increased difficulty of 
breathing, and an aggravated cough, with dark liquid sputa, a livid 
countenance, and a soft irregular and laboring pulse, the danger may be 
regarded as considerable. 

It is prudent to give a guarded prognosis in all cases, as some unfore- 
seen forboding symptoms may arise, but I believe that most cases of 
simple pneumonia, occurring in persons not otherwise diseased, or too 
advanced in life, will generally recover if they are subjected to proper 
treatment, or even to that which is not positively bad. 

Causes. — Atmospheric vicissitudes, or sudden exposure to cold and 
dampness, when the body is heated, is probably the most frequent cause 
of simple pneumonia. Inflammation of the lungs may, however, be pro- 
duced by various causes, such as direct violence, over exertion, irritating 
inhalations, violent anger, intemperance in eating and drinking, the me- 
tastasis of erysipelas, gout or rheumatism, kc. And besides, pneumonia 
is liable to be a complication of other diseases, such as bronchitis, hoop- 
ing-cough, measles, scarlatina, erysipelas, phthisis, and various organic 
affections of the heart. 

Treatment. — Pneumonia is an inflammtion in which, from the nature 



PNEUMONIA. 437 

of the parts inflamed, there is a good deal of congestion, and the conges- 
tion which is the immediate cause of the inflammation, is continued to a 
greater or less degree through the inflammatory stage. Now this con- 
gested condition of the inflamed lung may be greatly increased by any 
cause that serves to debilitate the patient, and on this account it is that 
bleeding, in this disease, should be resorted to with great caution. 

If the patient be seen during the first few hours after an attack, I be- 
lieve that general bleeding is seldom necessary or even beneficial. In 
such a case the feet should be placed in warm water, and if there is 
chilliness, the whole length of the back should be rubbed with a warm 
infusion of capsicum in vinegar, and the patient should be directed to 
drink warm sage tea, and should take a cathartic of calomel or podo- 
phyllin in castor oil, with twenty drops of laudanum, and the oil should 
be continued, with twenty drops of laudanum, every four hours, till a free 
operation is procured. Cups should at once be applied over the seat of 
the inflammation, and also along the side of the spine corresponding with 
the inflamed lung, and from three to six ounces of blood taken at first, 
and this may be repeated in a few hours, if necessary. 

The warm foot-bath may be repeated morning and evening, and after 
the operation of the cathartic, one-eighth of a grain of tartar emetic, in 
solution, with twenty drops of laudanum, and four drops of the fluid ex- 
tract of the veratrum viridi, may be given every four hours. The lau- 
danum quiets pain, while the antimony and veratrum are sedative, dia- 
phoretic, and expectorant, and together the combination tends to allay 
irritability, general fever, and to subdue the pulmonary inflammation. 

The bowels should be kept gently loose by castor oil or small doses of 
the sulphate of magnesia, if necessary, and soon after the operation of 
the first cathartic a large blister should be applied over the seat of the 
inflammation, and kept discharging, if possible, during the continuance of 
the inflammation. In this way, I believe most cases of simple pneumonia 
may be arrested, or controlled, if attended to in season, without general 
bleeding, or a mercurial course. 

But in some violent cases, occurring in strong, robust males, or in 
milder cases, if neglected for the first few hours, general bleeding may 
be necessary and should not be neglected; after which, the treatment 
may be conducted on the principles I have already suggested, with 
perhaps the addition of a mercurial course, if the inflammation is slow 
to yield. 

In cases in which a mercurial is indicated, calomel may be given 
immediately after the operation of the cathartic, in two grain doses every 
four hours, combined with five grains of Dover's powder, alternating 
with the antimony and veratrum, without the laudanum; the calomel may 
be continued till the inflammation yields, or the gums become slightly 
sore, when it should be omitted and the other treatment continued till 
the inflammation subsides and convalescence is fully established. 

Mucilage of gum arabic and crust coffee, one-half milk, may be 
allowed as nourishment and drink; and should a typhoid condition super- 
vene from over-depletion, or any other cause, the sulphate of quinine, 
wine-whey and broth may be administered as they are required. If, in 
spite of all these measures the lung passes on to a hepatized state, a 



438 DISEASES OF THE RESPIRATORY SYSTEM. 

plain, digestible and moderately nourishing diet should be allowed, and 
should an abscess form in the lung and point in the intercostal space, or 
burst into the cavity of the pleura, paracentesis should be performed and 
the matter evacuated. 

In such a state, alteratives and tonics are clearly indicated, and it is 
probable that in most cases, the iodide of potassium, with or without the 
syrup of the iodide of iron, in moderate doses, continued for a long time, 
will generally do best. The compound iodine ointment may also be 
applied to the affected side, and in certain favorable conditions in which 
there is firm adhesion between the pulmonary and costal pleura, a weak 
solution of iodine may be injected into the pulmonary abscess. 

SECTION IV.— BILIOUS PNEUMONIA. 

Having given in the preceding section the symptoms, anatomical char- 
acters, diagnosis, prognosis, causes, and treatment of simple pneumonia, 
I propose in the present section to give the general history, symptoms, 
diagnosis, cause and treatment of bilious pneumonia, without repeating 
what I have already stated in relation to the minute symptoms, anatomi- 
cal characters, diagnosis and prognosis, which will generally apply in 
bilious as well as in simple pneumonia. 

With these considerations let us proceed to inquire into the history, 
symptoms, diagnosis, cause and treatment of bilious pneumonia, in just 
so far as they are peculiar to this form of pulmonary inflammation. 

History. — In malarious districts, or in localities where bilious fever is 
a prevailing disease, in the spring and fall, or during the winter months, 
while the air is cool or damp, and sudden changes frequent; patients 
suffering from poisonous paludal exhalations, are often attacked suddenly 
with pneumonia. And from careful observation, in very many cases, I 
am satisfied that the following is the process, by which it is brought about. 

The miasmatic agent, whatever it may be, has been taken into the 
blood with the air, through the capillaries of the inter-cellular passages, 
and air-cells in the lungs; and also perhaps, by the skin, or by its be- 
coming entangled with the saliva, and carried into the stomach. This 
process has gone on in some one, or all these ways, till the amount of 
poison in the blood, has produced a debilitating effect upon the brain, and 
nervous system, so that the brain is rendered incapable of generating 
sufficient vital force to keep up the functions of the body; and the nerves 
are rendered imperfect distributors of the force which is generated. 

As a consequence, the functions of the liver become impaired; leading 
to loss of appetite, especially in the morning; to a bitter taste in the 
mouth ; to a coated tongue, and very imperfect digestion ; and finally, to 
great general debility. But this is not all; the whole muscular system, 
as well as the heart, becomes debilitated and relaxed; the circulation is 
impaired; respiration becomes languid; the blood is not properly decar- 
bonized; and hence the dullness, drowsiness, headache, &c. 

As a consequence of all this derangement, the circulation becomes still 
more sluggish; the blood fails by degrees, to be sent to the extremities; 
the heart and lungs labor to perform their functions, even imperfectly; 
the extremities become cold; and just at the time when a chill would have 



BILIOUS PNEUMONIA. 439 

ushered in a bilious fever, had nothing supervened; a hereditary predis- 
position ; a sudden change of temperature, or some other accidental cause 
irritates the lungs, and dooms them to an inflammation ; beginning gener- 
ally with the very chill, which would otherwise have been the commence- 
ment of a simple bilious remittent fever. 

Symptoms. — The patient is found in a half sitting posture, slightly 
turned upon one side. His face has a livid appearance ; his respiration 
is difficult ; he complains of a dull heavy pain in the side, upon which 
he lies, and has a frequent cough, which may be half stifled in some cases. 

By inspection of the chest, the affected side is found not to expand, at 
each inspiration, like the other side. 

By palpation, or laying the flat hands on corresponding parts of the 
two sides of the chest, the observation is confirmed. 

By percussion over the affected portion, a dull sound is elicited, and 
very unlike that produced by percussion upon corresponding parts of the 
opposite side. 

Auscultation detects a want of the natural respiratory murmur, and in 
its place a crepitus, very much like that produced by rubbing a lock of 
hair between the thumb and finger, caused by the passage of air through 
the minute inter-cellular passages, and air-cells, which are partially filled 
with a viscid half bloody mucus, more or less of which is expectorated, 
very soon after the inception of the inflammation. 

On further inquiry, it will -generally be found that the patient has suf- 
fered for two or three weeks from a bitter taste in the mouth, loss of ap- 
petite in the morning, has had slight constipation of the bowels, or 
diarrhoea, with a yellow appearance of the urine ; has had stupid or sleepy 
days, and restless nights, has had headache, with more or less coldness 
in the morning, and slight thirst at evening, &c. 

Diagnosis. — To distinguish bilious from simple pneumonia, it is only 
necessary to take into account the locality, the epidemic and endemic in- 
fluence, together with the general bilious symptoms which are developed 
in the case, to render the diagnosis clear. 

Causes. — The paludal poison is the cause of this disease. And it 
should be remembered that the patient has generally been suffering for 
several days, or perhaps weeks, from this poisonous miasmatic agent, 
which has debilitated the brain and nervous system, impaired digestion, 
cut off nutrition, let down the circulation, and finally would have led to 
a simple bilious remittent fever, except for the accidental local inflamma- 
tion set up in the lungs. 

And it should be still further remembered, that this local inflammation 
of the lungs by hindering a due decarbonization of the blood, further in- 
terrupts the circulation, and increases the liability of a fatal prostration 
as I have seen in too many cases. And finally, with this obstruction to 
the circulation through the lungs, and filling up of the air-cells, as well 
as contraction of the intercellular passages, and smaller bronchial tubes, 
there is great danger of sudden and fatal congestion, especially if both 
lungs are involved. 

Treatment. — We have then as a morbid condition in bilious pneumonia, 
a poisonous debilitating agent in the blood ; with general debility and its 
consequences, and an inflammation of one or both lungs, with probably 



440 DISEASES OF THE RESPIRATORY SYSTEM. 

a remitting tendency, masked by the local inflammation. The pulmonary 
inflammation in such cases may occasionally be active, but generally I 
believe it is decidedly passive. 

The indications then in the treatment of bilious pneumonia are plainly 
to equalize the circulation, arrest the inflammation, correct the bilious 
derangement, neutralize the morbific agent in the blood, sustain the sink- 
ing powers of the system, and finally to afford the patient a due supply 
of proper nourishment. 

To arrest the progress of the inflammation, cups should be applied 
wet or dry, according to the constitution of the patient, over the seat of 
the inflammation, and also along the side of the spine corresponding with 
the affected side. The cups along the spine take off the undue pressure 
on the spinal cord at this point, and lessen the irritation of the gan- 
glionic nerves, and as I believe, arrest the progress of the disease for the 
time at least. 

The cups over the seat of the inflammation, relieve the difficult breath- 
ing and troublesome cough, and improve the circulation through the 
lungs, by increasing the capacity of the intercellular passages and air- 
cells just as might be expected. 

To equalize the circulation, the warm foot-bath and friction along the 
spine, with a strong infusion of capsicum in vinegar, applied a little 
warm, is the most convenient and effectual. This will relieve the heavy 
pain in the lower portion of the spine, and also equalize the circulation, 
sending forth an agreeable glow of warmth to the surface of the body 
and extremities, and it often sends forth a gentle perspiration. 

The immediate urgent symptoms may generally in this way be allayed, 
and a decided check given to the local inflammation. The next step is 
to correct the bilious derangement. 

If the patient be a strong man, ten grains of calomel may be given in 
half an ounce of castor-oil, and the oil repeated if necessary. But if 
the patient is a female, or a male of a slender constitution, three blue 
pills may be given instead of the calomel, and followed in five or six 
hours by castor-oil. If, however, the patient be a young child, the mer- 
cury, with chalk, may be given in a teaspoonful of castor-oil, as it will 
generally be sufficiently active. The warm foot-bath may be repeated 
morning and evening for two or three days, as well as the friction along 
the spine with the warm pepper and vinegar. And after the first cup- 
ping, sinapisms may be applied to the chest, and also to the feet, gene- 
rally with very good effect. 

After the operation of the cathartic, there remains yet to be counter- 
acted the malarious morbific agent in the blood, to sustain the sinking 
powers of the system, to quiet irritability, and to counteract, if neces- 
sary, the local inflammation. To fulfill these indications, two or three 
grains of the sulphate of quinine may be given, with three grains of 
James's and five of Dover's powder every six hours, and continued till 
the fever is arrested. 

The sulphate of quinine counteracts the malarious morbific agent in 
the blood, sustains the sinking powers of the system, keeps the circula- 
tion equalized, and materially aids in increasing the capacity of the 
intercellular passages and air-cells, in the decarbonization of the blood, 



CATARRH. 441 

and also in its circulation through the lungs, and thus aids materially in 
the resolution of the local inflammation, as well as in arresting the 
general fever. The Dover's and antimonial powders, combined with the 
quinine, serve to allay restlessness and nervous irritability, to materially 
aid expectoration, and to promote perspiration during the early stages 
of the disease. 

After the fever is arrested, as it will generally be in three or four 
days, there may be a profuse perspiration, at which time the Dover's 
powder and antimonial may be discontinued, and one or two grains of 
camphor given with the quinine, if there is much restlessness, irritability 
or mental wandering. 

In some cases in which the bilious derangement fails to be corrected 
by the cathartic, or if the local inflammation is advanced considerably 
before the treatment is commenced, one or two grains of calomel for 
adults, or of mercury with chalk for children, may be added to the first 
few powders, to produce ,an alterative effect, and then, if necessary, a 
teaspoonful or two of castor-oil may be administered, to clear the alimen- 
tary canal. 

In cases in which there is great difficulty of breathing, with difficult 
expectoration, a teaspoonful of the fluid extract of the asclepias tuberosa 
may be given, with one-fourth of a grain of ipecac, every six hours, 
alternating with the quinine, for the purpose of promoting expectora- 
tion, &c. 

In many cases, especially if not seen early, blisters become necessary, 
over the seat of the inflammation, and when they are, should generally 
be applied after the cupping and operation of the cathartic. And if, as 
is often the case, there is much gastro-intestinal irritation, a blister 
should be applied to the epigastrium. 

Mucilage of gum arabic may be allowed, during the whole course of 
the disease, as it is grateful to the patient, favors expectoration, and is 
slightly nourishing. The patient may also be allowed to drink freely 
of crust coffee, one-third milk, for the first two or three days, and later 
one-half or two-thirds milk, to be taken warm, whenever drink is re- 
quired. And as soon as there is an appetite for food, toast or other 
plain varieties of digestible food may be allowed, three times per day, 
at regular meal hours. After the patient gets a tolerable appetite, a 
grain or two of quinine only need be given, after each meal, till health 
is perfectly restored. 

In bilious pleurisy, or pleuro-pneumonia, the pain is more acute than 
in cases in which the pleura is not involved, and the patient lies on the 
well side, but the indications are in all respects the same as in bilious 
pneumonia, uncomplicated with pleuritic inflammation. 

SECTION V.— CATARRH. 

By catarrh, from *a*a, " downwards," and p*w, "I flow," I mean here, 
a discharge of fluid from the Schneiderian membrane, which lines*; the 
nasal fossse, and extends to the different cavities connected with the 
nose. 

The Schneiderian or pituitary membrane appears to be formed of two 



442 DISEASES OF THE RESPIRATORY SYSTEM. 

layers, the one in contact with the bone being fibrous, the other mucous, 
the two being intimately united. This membrane, after lining the nasal 
fossae, penetrates the sphenoidal, ethmoidal, frontal, and maxillary 
sinusses, in which it appears to assume a thin and more exclusive mucous 
character. The Schneiderian membrane is continuous through the nasal 
duct with the conjunctiva, along the enstachian tubes with the mastoid 
cells and tympanum, and through the posterior nares with the pharynx 
and mouth. 

The pituitary membrane contains the expansion of the olfactory nerves, 
by which the impression of odors are received ; and in a healthy state, it 
secretes sufficient mucus to lubricate its surface. This membrane how- 
ever, from repeated colds, from a scrofulous, rheumatic, or syphilitic 
condition of the system, and from various other causes, is liable to a 
diseased condition, in which, with various other unpleasant symptoms, 
there is a copious and sometimes offensive secretion, which may flow 
from the nose, or pass by the posterior nares to the fauces. 

Symptoms. — The symptoms then of this disease, which I have called 
catarrh, are as follow. In most cases, after a succession of colds, there 
is noticed an increased discharge from the nose, and especially into the 
throat, during the night. And there may be at first, or if not, there is 
very soon more or less pain experienced in the nose, forehead, cheeks 
and eyes. 

These symptoms may continue on for weeks, months, or even years, 
with only perhaps a slight increase, and an occasional aggravation from 
colds, exposure to dampness and other accidental causes. More gene- 
rally, however, if the disease is not arrested, the discharge gradually in- 
creases and perhaps becomes offensive, the sense of smell is gradually 
impaired, and in some cases finally lost, the pain in the forehead in- 
creases or becomes more constant and distressing, the eyes become weak, 
watery and painful, the sight more or less impaired, a constant hawking 
and spitting becomes necessary to clear the throat, a troublesome cough 
supervenes, and if the disease continues, partial deafness, dizziness, and 
various other unpleasant symptoms are liable to arise. 

If this disease continues, as it often does, for a term of years, it may 
by extension produce ophthalmia, pharyngitis, gastritis, laryngitis, tra- 
cheitis, bronchitis, and indirectly it may lead to tubercular phthisis and 
various other affections. 

Causes. — A scrofulous, rheumatic, or generally depraved condition of 
the system, strongly predispose to this affection, as well as a syphilitic 
taint. The exciting causes are various, such as repeated colds, damp 
apartments, and especially sleeping rooms ; wet feet, insufficient clothing, 
dirty filthy habits, very hot rooms, wearing furs about the neck and face, 
taking too much drinks, snuffing tobacco and various other imprudences. 

Nature. — Congestion, irritation, inflammation, or ulceration of the 
Schneiderian membrane, is probably the cause of the excessive morbid and 
often offensive discharge, which constitutes the essential feature of this 
disease. 

In cases of catarrh occurring in good constitutions from accidental 
causes, the congestion, irritation or inflammation probably differs very 
little, if at all, from ordinary inflammation, affecting other portions of 



CATARRH. 443 

mucous membranes. But when the disease occurs in rheumatic, scrofu- 
lous or otherwise depraved constitutions, the disease of the Schneiderian 
membrane generally partakes of the nature of the constitutional de- 
rangement, and especially is this the case if there is a syphilitic taint. 

The pain attending this disease, and usually referred to the nose, fore- 
head or cheek, is no more than might be expected from the nature of 
the parts involved and the extent of the disease. And the same is true 
in relation to all the other symptoms which attend this disease, 

Treatment. — To arrive at the indications of treatment in this disease, 
it is necessary to ascertain how far the affection may be the result of a 
general or constitutional derangement, such as a scrofulous, rheumatic or 
syphilitic condition, and how far it is local, depending upon accidental 
causes, such as repeated colds, &c. In the first place then, all the habits 
of the patient which would tend to perpetuate the disease, should be 
corrected, and the general derangement of the system, as well as the 
local disease, should receive a due share of attention in the treatment. 

The patient should be directed to take proper food at regular hours, 
with a very moderate allowance of drinks ; should be properly clad with 
flannel next the skin, in cool or damp weather, and should keep dry feet. 
Furs should not be worn about the neck or face, and the patient should 
avoid damp apartments, or very heated rooms, and the skin should be kept 
clean. 

In cases depending upon a rheumatic, syphilitic or scrofulous condition 
of the system, five grain doses of the iodide of potassium may be given, 
three times per day, in four ounces of the compound decoction of sarsa- 
parilla, and continued for several weeks, if necessary. After having 
continued the iodide of potassium for a reasonable time in scrofulous and 
syphilitic cases, ten drops of the syrup of the iodide of iron may be given 
three times per day, in the compound decoction or fluid extract of sarsa- 
parilla ; in connection, in scrofulous cases, with moderate doses of cod 
liver oil given an hour after each meal. 

In this way the general derangement of the system may generally be 
materially improved, and if the patient takes but little drinks, the 
morbid discharge from the nose may be lessened or corrected, and 
the irritation, inflammation, or ulceration of the Schneiderian membrane, 
upon which it directly depends may be removed. In case, however, the 
morbid discharge from the nose continues after the general treatment, 
and in all cases in which general treatment is not indicated, local appli- 
cations may be required to the Schneiderian membrane. 

In simple recent cases in which the discharge is not offensive, or very 
copious, ten drops of sea-water, snuffed up the nose from the hollow of 
the hand, once each day after breakfast, for a time may cure the disease. 
If, however, the discharge is copious, but not offensive, a solution made 
by adding a drachm each of alum and loaf sugar to eight ounces of water, 
and used as suggested above, may be more effectual. 

In all cases of catarrh, however, in which the nasal discharge is offen- 
sive, consisting of whitish or yellowish muco-purulent, or sanious bloody 
matter, as well as in all protracted or obstinate cases of this disease, a 
weak solution of corrosive sublimate, is the very best local application. 
Four grains of corrosive sublimate may be added to half an ounce of the 



444 DISEASES OF THE RESPIRATORY SYSTEM. 

compound spirit of lavender, and sufficient water added to make eight 
ounces of the solution. Of this ten drops may be snuffed up the nose 
once each day, as suggested above, and continued till a cure is effected. 

SECTION VI.— LARYNGITIS. 

By laryngitis, I mean here inflammation of the larynx of an acute or chro- 
nic character, involving generally the mucous membrane and submucous 
tissue, and leading in some cases to the formation of a pseudo-membrane 
in advanced life, as croup does in infancy and childhood, and in chronic 
cases to ulceration. 

The larynx, it will be remembered, is situated at the superior and 
anterior part of the neck, at the top of the trochea, with which it com- 
municates. It is composed of the thyroid, cricoid, and two arytenoid 
cartilages, is moved by a number of muscles, and lined by a mucous mem- 
brane which being reflected, constitutes the superior ligaments of the 
glottis. Beneath the mucous membrane is a submucous tissue, and the 
larynx is also supplied with arteries and nerves. It gives passage to the 
air in respiration, and it is in the glottis, which is a narrow oblong aper- 
ture in the larynx, that the voice is produced by the chordae vocales. 

The epiglottis is the fibro-cartilaginous covering of the glottis, attached 
anteriorly to the thyroid cartilage, and covered on both surfaces by the 
mucous membrane of the larynx and pharynx. This in a healthy state 
covers accurately the glottis, at the moment of deglutition, and prevents 
the passage of alimentary substances into the air tubes. The larynx, 
thus situated and constituted, is liable to become inflamed, especially its 
mucous membrane and submucous tissue, the symptoms of which we will 
now proceed to consider. 

Symptoms. — Laryngitis, in its acute form, usually commences with a 
slight chill, followed by febrile reaction, attended with soreness in the 
fauces, more or less uneasiness in swallowing, and tenderness in the 
larynx to external pressure. The voice soon becomes changed into a 
thick, hoarse whisper, and on inspiration the air appears impeded in its 
passage, in consequence of the narrowing of the glottis, or laryngeal 
passage, from congestion of its mucous membrane and submucous 
tissue. 

By placing the ear over the larynx a whistling, or hoarse, dull, crow- 
ing sound is heard, by the obstruction offered to respiration in conse- 
quence of the laryngeal inflammation. On examination of the fauces, 
the soft parts are found red, swelled, or of an cedematous appearance. 

As the inflammation passes on, a moderate secretion takes place, in 
and about the larynx, a part of which is expectorated with more or less 
saliva ; constituting together a ropy, glairy fluid. Another portion of 
this mucus accumulates in the larynx, or passes down the upper part of 
the trachea, and produces, during inspiration and expiration, a gurgling 
noise, or the tracheal rattle. 

The pulse is usually frequent, contracted and tense, but in some cases 
it remains nearly natural, at least during the first stages. The face is 
generally pale, and the tongue white, with numerous red points, and 
covered with a layer of nearly transparent mucus. 



LARYNGITIS. 445 

When the disease is fully developed, deglutition becomes very difficult 
and painful, producing often paroxysms of suffocative breathing. The 
temperature of the surface is apt to become uneven, being higher than 
natural in some parts, and lower in others. And any effort to cough 
results in a low, grunting noise in the throat. 

The respiration becomes more oppressed and difficult, if the disease 
passes on unsubdued; the patient starts up suddenly in bed, the lips 
assume a livid or purplish color, the surface becomes cold, the pulse fre- 
quent and feeble, the countenance becomes ghastly, the skin becomes 
covered with a clammy sweat ; and, finally, coma, delirium and death are 
the result. The immediate cause of death may be suffocation, from clo- 
sure of the glottis, or laryngeal passage, or it may be from imperfect 
decarbonization of the blood. 

In some instances laryngitis is very insidious in its approach, and 
rapid in its progress, terminating in death in a few hours. In such cases, 
there is probably very great congestion of the laryngeal mucous mem- 
brane, and also of the submucous areolar tissue, as well as some spas- 
modic contraction of the larynx, or its muscles and vocal cords. 

The inflammation in laryngitis evidently commences in the laryngeal 
mucous membrane, and in mild cases, or if arrested early, may extend no 
further. But in violent or unsubdued cases, the submucous areolar tis- 
sue becomes either congested, inflamed or oedematous, in the latter stages 
of the disease, before a fatal termination. 

In violent or protracted cases the epiglottis generally becomes very 
much inflamed, or oedematous, and may produce suffocation, by inter- 
rupting the passage of air to the lungs. In such cases, the epiglottis is 
sometimes found red, erect, thickened and very much swelled. The in- 
flammation may, in rheumatic patients, extend to the perichondrium, in 
which case there is, in addition to the ordinary symptoms of laryngitis, 
a severe, dull, heavy pain in the part. 

Laryngitis may terminate in suppuration, small abscesses forming 
about the larynx; or a pseudo-membrane may form on the tonsils, epi- 
glottis, and even extend into the laryngeal cavity, in some rare cases of 
this disease ; or the disease may assume a chronic character. 

Anatomical Characters. — The laryngeal mucous membrane is found 
softened, thickened and gorged with blood, and the sub-mucous areolar 
tissue is distended with a bloody, serous, or sero-purulent fluid, especially 
in the upper part of the larynx and epiglottis. 

The surface of the laryngeal mucous membrane is usually covered 
with mucus, and coagulable lymph is sometimes found in patches on its 
surface, or effused into the sub-mucous areolar tissue. And in oedema- 
tous cases, there is a copious effusion of serum, occupying mainly the 
sub-mucous tissue beneath the mucous membrane. And in chronic cases 
ulceration, &c, may be found, of the mucous and other laryngeal tissues. 
Causes. — It is probable that exposure to cold and dampness when the 
body is heated, is by far the most frequent cause of laryngitis, as it- 
occurs in adults. But the disease may be produced by a variety of 
causes, such as excessive use of the voice, direct injuries, extension of 
inflammation from surrounding parts, the abuse of mercury, metastasis 
of erysipelas, and, finally, it may arise as a complication during the con- 



446 DISEASES OF THE RESPIRATORY SYSTEM. 

thmance of scarlatina, small-pox, and various other affections. Or in 
its chronic form, it may arise from a syphilitic taint, or a scrofulous con- 
dition of the system, &c. 

Treatment. — In mild cases of laryngitis, a full dose of the sulphate of 
magnesia, the warm foot-bath at evening, for two or three nights, a solu- 
tion of alum in sage tea, sweetened with honey or loaf sugar, used as a 
gargle, and a dry flannel worn about the neck, especially during the 
night, may be sufficient to remove the disease. 

In neglected or violent cases, however, active measures may be neces- 
sary from the very first, to prevent suffocation. The feet should be 
placed in warm water till free perspiration appears, the patient being 
allowed as a drink, warm sage tea. Cups, too, should be at once applied 
to the back of the neck, and three or four ounces of blood taken at first, 
and if necessary, several leeches should be applied to the larynx, and 
the blood thus lost will generally be sufficient, except in very robust 
men, in which general bleeding may occasionally be indicated. 

A full dose of calomel or podophyllin should be given in half an ounce 
of castor-oil, and the oil repeated, if necessary, till free catharsis is pro- 
duced. After the operation of a cathartic, nauseating doses of tartar 
emetic or ipecac should be given every four hours, and if the case is 
severe, or threatens to be obstinate, four grains of Dover's powder, with 
two grains of calomel, may be given every four hours, alternating with 
the antimony or ipecac, and continued till the disease is checked, or 
slight ptyalism is produced. 

The warm foot-bath should be repeated morning and evening ; a blis- 
ter should be applied to the larynx, if necessary, after the leeching, and 
should the disease pass on, and suffocation be threatened, the larynx or 
trochea should be opened, and thus a passage be furnished for the air to 
and from the lungs, till the laryngeal inflammation is subdued, when it 
should be allowed to heal. 

Should laryngitis pass on and become chronic, and in cases that are 
chronic from the first, the diet, habits, and general condition of the 
patient should be corrected, and local applications, both external and in- 
ternal, should be resorted to as the case may require. 

In most chronic cases there is a thickening of the laryngeal mucous 
membrane, as well as more or less oedema or congestion of the submucous 
areolar tissue, and it appears to depend, in many cases, upon a syphilitic 
taint, or a scrofulous condition of the system. 

In cases of this character the iodide of potassium, in five grain doses, 
three times per day, before each meal, given in an ounce of simple syrup, 
is the best alterative, and it should be continued for several weeks, if 
necessary. In scrofulous cases, after having continued the iodide of 
potassium for a reasonable time, ten drops of the syrup of the iodide of 
iron may be given in its stead, and a tablespoonful of cod liver oil three 
times per day, an hour after each meal, and continued till the general 
condition is corrected. 

Blisters should be applied over the larynx at first, and then iodine 
ointment may be continued, morning and evening, while the disease lasts. 
Internally in very mild cases, equal parts of alum and loaf sugar, pul- 
verized very fine, may be carried between the thumb and finger into the 



TRACHEITIS. 447 

fauces, and then by a short inspiration, it may be drawn into he larynx, 
and this may be repeated at evening, each day, as long as mav be re- 
quired. 

In cases, however, in which this general and local treatment fails in 
effecting a cure, a solution of the iodide of potassium, or of the crystals 
of nitrate of silver should be applied directly to the mucous membrane of 
the larynx, by means of a curved whalebone, with a sponge firmly 
attached to the end of it, as recommended by Dr. Horace Green, of New 
York. 

In cedematous cases, a solution of the iodide of potassium, of the 
strength of two drachms of the iodide, to an ounce of rain water, may 
be applied every other day, for two or three weeks, and then it may be 
used two or three times per week, till a cure is affected, the strength of 
the solution being gradually increased, if necessary. If, however, as the 
oedema is removed, the mucous membrane still remains inflamed or ulce- 
rated, and in all severe cases in which there is little oedema, a solution of 
crystalized nitrate of silver, of the strength of a drachm to the ounce of 
rain water, should be applied as suggested above, and continued till a 
cure is effected. 

SECTION VII.— TRACHEITIS— {Rattles.) 

By tracheitis, I mean here inflammation of the mucous membrane of 
the trachea, involving sometimes other tracheal tissues, the disease not 
extending, however, to the larynx, as I believe it does in all genuine 
cases of croup. 

The trachea, it will be remembered, is a "fibrocartilaginous and mem- 
branous tube," partially flattened behind, situated before the vertebral 
column, and extending from the larynx to opposite the third dorsal ver- 
tebra, where it divides into the two bronchia, which go to each lung. 

It conveys air to and from the lungs, during respiration, for which 
function it is admirably fitted by the peculiarities of its structure, being 
composed of fibrocartilaginous rings, except the posterior third, which is 
made up by a fibrous membrane. The rings are connected with each 
other by a fibrous membrane, and transverse muscular fibres extend be- 
tween the extremities of the cartilages posteriorly, and besides, there are 
posteriorly, longitudinal elastic fibres, which lie beneath the mucous 
membrane, and passing down, they enclose the entire cylinder of the 
bronchial tubes to their extremities. 

The trachea is lined internally by a mucous membrane, and has a 
supply of glands which pour their secretion upon, and lubricate the 
mucous membrane. The tracheal arteries are derived from the superior 
and inferior thyroidal, and its nerves from the pneumogastric and the 
cervical ganglia. The trachea thus situated and constituted, is liable to 
become inflamed, especially its mucous membrane, the symptoms of 
which we will now proceed to consider. 

Symptoms. — Tracheitis sometimes comes on suddenly, and hastens to 
a fatal termination in a few hours. More generally, however, its ap- 
proach is gradual, there being at first, a dry hoarse cough, with slight 
difficulty of breathing, with or without slight chills, alternating with 
flashes of heat, &c. 



448 DISEASES OP THE respiratory system. 

If, during this early stage, the ear be placed over the trachea; a 
wheezing, whistling, or crowing sound is heard ; loud or slight, according 
to the amount of the tracheal obstruction. 

The respiration gradually becomes more difficult, as the disease ad- 
vances, till it becomes very distressing ; and the disease, if it progresses 
unchecked, often assumes an alarming degree of violence. The counte- 
nance is flushed; the eyes are injected and heavy; the pulse frequent, 
tense, and quick ; the skin hot and dry, and the respiration extremely 
difficult and anxious. 

The cough, which had been dry, now produces a rattling, or gurgling 
sound, in consequence of the copious secretion of a tenacious fluid into 
the trachea. And if the ear be placed over the trachea, a gurgling sound, 
or the tracheal rattle will be heard along its whole course ; but more dis- 
tinctly in the lower part of the trachea. If the disease continues, the 
breathing acquires at last a degree of oppression, extremely distressing ; 
the patient frequently manifesting in the expression of countenance and 
actions, the greatest degree of anguish and suffering. The head is thrown 
back, and mouth kept open ; the eyes are half closed ; the lips livid ; the 
face pale, and covered with perspiration; the extremities become cold; 
and finally the patient dies, apparently from suffocation, caused by the 
accumulation of the viscid secretion, in the lower part of the trachea, 
and larger bronchial tubes. 

Anatomical Characters. — False membrane is generally found along the 
trachea, from near its superior portion, to its bifurcations, and the mu- 
cous membrane is reddened, and sometimes softened and thickened. The 
same appearance is also presented in some cases, in the larger bronchial 
tubes, if there has been an extension of the inflammation to the mucous 
membrane lining the larger bronchia. 

Diagnosis. — Tracheitis may be distinguished from laryngitis, by careful 
attention to the following symptoms. In laryngitis, the voice is more 
changed, in the early stage of the disease, and in fact, all through, than 
in tracheitis. In laryngitis, the early peculiar whistling, or crowing 
sound, as well as the mucous rattle of the latter stage, are heard most 
distinctly in the larynx, and upper part of the trachea; while in tracheitis 
the dry or crowing sound is less distinct, and heard along the trachea, 
and the later tracheal rattle is heard most distinctly towards the lower 
part of the trachea. 

From laryngo-tracheitis or croup, this disease differs in the following 
particulars: In croup, the early crowing sound, produced by respiration, 
as well as the mucous rattle of the latter stages, are heard most distinctly 
in the larynx, and upper part of the trachea; while in tracheitis, or 
rattles, the dry or crowing sound is heard only along the trachea ; and the 
tracheal rale or rattle is heard only in the lower portion of the trachea. 
To this sound there maybe added the mucous rale, with which it mingles, 
caused by the presence of mucus in the larger bronchial tubes. 

Finally, the peculiar gurgling or tracheal rattle always so conspicuous 
in tracheitis, and which is heard distinctly without applying the ear to 
the part, is sufficient to distinguish this disease from croup, laryngitis, 
bronchitis, and in fact all other affections. In fact, it is from this pecu- 
liarity that the common name of rattles has been applied to this disease, 



LARYNGO-TRACHEITIS. 449 

and from the fatal tendency of the disease, the very name has become a 
terror in some localities, and in some families, greater, if possible, than 
that of croup. 

Causes. — Tracheitis, or rattles, is confined almost exclusively to children, 
generally occurring before the fifth year of age, but it sometimes occurs 
in very advanced age. In some families there appears to be a congenital 
predisposition to this variety of disease ; at least some children are more 
liable to attacks of this affection from slight causes than others. 

The disease may arise as a complication in scarlatina, measles,, and 
various other exanthematous fevers, but the most frequent cause is cold 
or atmospheric vicissitudes, combined with dampness, and a low or 
changeable electrical state of the atmosphere. 

Treatment. — Warm pediluvia, warm sage-tea, and sinapisms over the 
trachea, and to the bottom of the feet, may be sufficient to arrest and 
remove mild cases of this disease. If, however, the disease passes on, 
and in all severe cases of tracheitis, an emetic of antimony or ipecac 
should be administered, and free vomiting produced; after which, a full 
dose of calomel or podophyllin should be administered in castor oil, and 
the oil repeated if necessary. 

After the operation of the cathartic, nauseating doses of ipecac or 
antimony should be given every four hours, and alternating with this in 
severe cases, small doses of calomel may be given till an impression is 
produced on the inflammation ; or slight ptyalism is produced. Leeches 
may be applied along the trachea at first, and later, mustard ; and should 
the disease pass on and become chronic, a blister may be applied in this 
region, or to the back of the neck. 

If, after the tracheal secretion becomes copious, symptoms of suffoca- 
tion from its presence supervene, an emetic of ipecac or of the compound 
syrup of squills should be given, as young children can seldom be induced 
to raise anything by coughing. 

Should tracheitis pass on and become chronic, the mucous membrane 
being thickened and covered more or less with a pseudo-membrane, and 
the various tissues of the trachea congested or oedematous, there is 
always difficult breathing and a more or less troublesome cough. In 
such cases, the diet, clothing, and all the habits of the child should be 
properly cared for, and full doses of the iodide of potassium should be 
given in simple syrup, three times per day, before each meal, and con- 
tinued till the condition is corrected, so far as it may be. There is also 
in such cases, more or less spasm of the trachea; to remove which, and 
to allay the troublesome cough, small doses of the tincture or fluid extract 
of stramonium, with moderate doses of the compound syrup of squill may 
be given four times per day, for a time at least. 

SECTION VIII.— LARYNGO-TRACHEITIS— ( Croup.) 

By laryngo-tracheitis or croup, I mean inflammation with congestion 
of the laryngo-tracheal mucous membane, attended, generally, with more 
or less spasmodic contraction of the larynx and trachea, all of which 
tend to produce a narrowing of the laryngo-tracheal passage, producing 
a marked change in the voice, cough, and respiration. 
29 



450 DISEASES OF THE RESPIRATORY SYSTEM. 

We have seen that the larynx and trachea are liable to become sepa- 
rately inflamed, the inflammation of one of "which I have called laryn- 
gitis, and that of the other tracheitis ; we shall now see that the larynx 
and trachea are liable to become inflamed at the same time, constituting, 
with more or less spasm, what I have here called laryngo-tracheitis or 
croup. 

I shall restrict the term croup to those cases in which, with more or 
less spasm of the larynx and trachea, there is inflammation of the mucous 
membrane of the larynx and trachea, and shall treat of cases which are 
purely spasmodic, without being inflammatory, as a variety of asthma, 
in its proper place. 

In order to appreciate the symptoms which are developed in croup, 
it is necessary to bear in mind the anatomy and physiology of the larynx 
and trachea, and also the character of the disease under consideration, 
remembering that all cases are inflammatory, and most cases more or 
less spasmodic. 

Symptoms. — There are generally slight symptoms which precede an 
attack of croup, such as a slight cough, hoarseness, &c, which should 
serve as a warning to parents whose children are predisposed to this 
affection. These premonitory symptoms are usually aggravated towards 
evening, and during the night, and are sometimes attended with slight 
febrile symptoms. 

In some cases, however, these premonitory symptoms do not appear, 
or are so obscure as to produce no alarm, till suddenly during the night 
the child, perhaps before waking, is heard to cough with a peculiar 
hoarse sound, as if it had coughed through a large tube. As the child 
wakes, or is roused, the voice produces the same hoarse sound which 
characterized the cough, and the respiration also produces a peculiar 
sonorous, shrill, crowing sound, which is heard in the larynx, and more 
or less along the trachea to its bifurcation. 

This peculiar crowing, respiratory sound, hoarse voice, and cough, 
arises from inflammation, with congestion of the mucous membrane of 
the larynx and trachea, and also in part, in most cases, from more or 
less spasmodic contraction of the larynx and trachea, caused by the ex- 
cessive irritation of the muscles and other tissues of the parts. 

A slight redness of the fauces sometimes exists, and also tenderness 
of the larynx, and the child often complains of uneasiness in the throat, 
and says he is choking. Sometimes these symptoms subside in an hour 
or two, with very little more than warm drinks, and placing the feet in 
warm water. But more generally the disease passes on, even to a fatal 
termination, unless it be arrested by prompt and proper treatment. 

If the disease passes on unchecked, the cough becomes husky, and 
almost imperceptible; the voice becomes a hoarse whisper, the respira- 
tion is wheezing, the countenance pale and lips livid, the eyes languid 
and pupils dilated, the tongue is loaded, and there is considerable thirst, 
but the skin becomes gradually cooler. Finally, in fatal cases, the eyes 
become sunken, the extremities cold, the respiration becomes frequent, 
interrupted and laborious, and after gasping for a longer or shorter time, 
the child dies. 

Croup may terminate favorably or fatally in a few hours, or it may 



LARYNGO-TRACHEITIS. 451 

continue for three or four days, and in some rare cases, the little patient 
recovers after the most unpromising symptoms. In cases that recover 
after a protracted course, there is usually more or less matter expecto- 
rated, showing that the inflammation has terminated. In some instances 
this matter is of a purulent appearance, while in other cases it consists 
of thin flakes, of an adhesive character. 

Diagnosis. — Laryngo-tracheitis may be distinguished from simple 
laryngitis, by the peculiar crowing sound being heard all along the tra- 
chea, while in laryngitis, the sound is only heard in the larynx. Be- 
sides this, laryngitis generally occurs in adults, while croup usually 
occurs during infancy or childhood. 

Laryngo-tracheitis may be distinguished from simple tracheitis by the 
marked change in the voice and cough in croup, while if the inflamma- 
tion is confined to the trachea, though there is the crowing respiratory 
sound along the trachea, the voice and cough are not so markedly 
changed. 

Anatomical Characters. — The post-mortem generally reveals the pre- 
sence of a pseudo-membrane of an opaque white or yellowish appearance, 
lining the larynx, trachea, and sometimes extending to the bronchial 
tubes. 

In some cases this membrane forms nearly perfect tubes, but often it 
consists of mere patches along the mucous membrane. The mucous 
membrane is generally found reddened, and in some cases softened, and 
more or less thickened. The bronchial tubes may be reddened, and they 
generally contain more or less opaque white, green, or yellow puriform 
mucus. 

Causes. — There is in some families a strong hereditary predisposition 
to croup, depending, in part at least, upon a weak or relaxed condition 
of the tissues, and especially of the mucous and cellular tissues of the 
larynx and trachea, in consequence of which they become readily con- 
gested, irritated and inflamed by a slight exciting cause. 

The most frequent exciting cause is cold, or atmospheric vicissitudes, 
combined with moisture, and a variable electrical state of the atmosphere. 
And when we take into account the extent of mucous surface exposed 
to the air and moisture in the larynx and trachea, it does not appear 
strange that a sudden exposure to cold and dampness should, by check- 
ing the perspiration, and also the mucous exhalation in the larynx and 
trachea, produce congestion, irritation, and inflammation of the mucous 
membrane of these parts. Nor is it strange that when these parts be- 
come irritated, congested and inflamed, there should be some spasmodic 
contraction of the larynx and trachea, as there evidently is in some 
cases, if not in all. 

Prognosis. — Frightful as this disease is, and fraught with danger as 
it is from the very first, by proper treatment in due season most cases 
should recover. At least such has been my experience in the treatment 
of this disease. If the case be neglected, however, or improperly 
treated, the disease may pass on to a fatal termination in a few hours. 

Treatment. — If, while the premonitory symptoms which generally pre- 
cede croup are being developed, the child take a few drops of hive-syrup, 
with an equal quantity of paregoric, every six hours, for a day or two, 



452 DISEASES OF THE RESPIRATORY SYSTEM. 

and the feet be placed in warm water at evening, for two or three nights, 
and the child be kept warm, especially through the night, the disease 
may generally be prevented, or arrested before it is fully developed. 
Hence all families that are predisposed to croup should be supplied with 
hive syrup, in order to be able to administer it as soon as the premo- 
nitory symptoms occur. 

But if the disease be neglected, or is not arrested during the forming 
stage, active and persevering measures may be required. The child 
should have the feet placed in warm water ; allowed a little sage-tea, and 
immediately vomited. 

As an emetic in croup, the compound syrup of squill, I believe, is the 
very best. For a child a year old, ten drops of the hive syrup may be 
given every ten minutes, till free vomiting is produced; after which, it 
may be continued with an equal quantity of the tincture of lobelia, and 
two drops of the tincture of stramonium every three hours at first, and 
later, every six hours, till every symptom of the disease subsides. After 
the emetic, a full dose of calomel or podophyllin should be administered 
in castor oil, and a free evacuation of the bowels secured. Sinapisms 
may be applied over the larynx and trachea, if necessary; or if the 
danger of suffocation appears great, slight vesication may be produced 
over the larynx by Granvill's lotion. Or if this is not at hand, a blister 
may be applied, if the disease is obstinate. 

In obstinate cases it may become necessary to repeat the vomiting 
with the hive syrup ; and especially is this the case if the trachea and 
bronchia appear to be filling with a viscid secretion threatening suffoca- 
tion. Finally, in cases in which suffocation appears inevitable and mainly 
from obstruction in the larynx, tracheotomy may be performed. 

SECTION IX.— ACUTE BRONCHITIS. 

By acute bronchitis I design to designate here all cases of inflamma- 
tion of the bronchia, not of a protracted or lingering character. 

Now, to understand this disease, it is necessary to remember that the 
two bronchia proceed from the bifurcation of the trachea to their corres- 
ponding lungs. And that on entering the lungs, they divide into two 
branches, and each of these divides and subdivides very much like the 
branches of a tree to their ultimate termination in the intercellular pass- 
ages or air-cells. 

The bronchia diminish in size till they are reduced to about ^th of an 
inch in diameter, and reach within |th of an inch of the surface of the 
lung, at which size they terminate in elastic membrane, interspersed with 
muscular fibres, and assume the name of intercellular passages. 

The bronchial tubes consist, it will be remembered, of cartilaginous 
rings, circular muscular fibres and longitudinal elastic tissue ; and they 
are lined throughout with mucous membrane, continuous with that of the 
larynx and trachea. 

The bronchia perform the important function of transmitting air to 
and from the intercellular passages and air-cells in every part of the 
lungs ; and from their nature, structure and exposure are liable to be- 
come inflamed; especially their mucous membrane, but involving more or 



ACUTE BRONCHITIS. 453 

less their whole structure ; the symptoms of which, in its acute form, we 
will now proceed to consider. 

Symptoms. — Bronchitis generally commences with lassitude, chilliness, 
slight cough, and a sense of tightness, and oppression in the chest. The 
disease often appears to be of no very serious character, as there is little 
or no pain in the chest; and but slight febrile reaction. But as the dis- 
ease advances, the oppression increases ; the countenance becomes anxious, 
the respiration more laborious, and a peculiar wheezing respiratory sound, 
resulting from a narrowing of the bronchial tubes, is distinctly heard. 

By placing the ear over the larger bronchial tubes, the sonorous, with 
perhaps the sibilating ronchus, is distinctly heard; which, as we have 
seen, results from the passage of air through the constricted, or narrowed 
bronchial tubes, of different sizes. 

The cough at this stage, is dry and hoarse, and there is generally a 
slight hoarseness of the voice. But after the disease has progressed, 
there is a copious secretion of viscid transparent mucus into the bronchial 
tubes, which produces a marked change in the voice, cough, and respira- 
tory sound. The cough becomes less hoarse, and is attended with a 
rattling noise in the larger bronchia, in consequence of the viscid mucus 
which they contain. The voice is also less hoarse ; but more or less in- 
terrupted from the same cause. 

By applying the ear to the chest, the mucous, or sub-crepitant rale or 
rattle is distinctly heard, according as the larger or smaller bronchial 
tubes are mainly involved. The mucous rale may be heard in one part 
of the chest, and the sub-crepitant in another, or there may be a mingling 
of the two sounds in the same part. 

As the inflammation is terminating by resolution, the secretion becomes 
less viscid, and assumes a yellowish color, and the air passes with less 
resistance. This does not, however, very materially affect the respiratory 
sound, or that of the voice or cough, while the secretion lasts. 

In most cases of acute bronchitis, severe pain is felt in the forehead ; 
and if the secretion of the bronchia is very copious, more or less drowsi- 
ness usually attends. The tongue is white, and covered with a transparent 
mucus. The skin is dry; but not generally much elevated above its 
natural temperature ; animal heat being cut off by the diminished com- 
bustion, and drowsiness being produced by the retained carbon. 

Children are very liable to bronchitis, and it generally commences with 
a slight hoarse cough, which soon changes to a rattle, the respiration being 
correspondingly changed. The countenance becomes pale, the pulse 
frequent and tense, the hands and feet cool; but the temperature of the 
trunk may remain nearly or quite natural. 

If the disease passes on, the respiration becomes exceedingly variable, 
and more oppressed ; the lips become livid, and not unfrequently the 
cheeks, and the disease may terminate fatally, as early as the third or 
fourth day. In robust children, the febrile reaction may be quite marked 
in the early stage of the disease ; but this is not invariably the case. 

Such are the usual symptoms of acute bronchitis, as it occurs in adults 
or during infancy or childhood; liable of course to variation from con- 
stitutional and other causes. 

Diagnosis. — Acute bronchitis may be distinguished from all other 



454 DISEASES OF THE EESPIRATOKY SYSTEM. 

affections by the tightness in the chest, with little or no pain, the sono- 
rous and perhaps sibilating ronchus in the early stages, and the mucous 
with the sub-crepitant rales in the latter ; and, finally, by the headache, 
cold extremities, and moderate febrile reaction in this disease. 

Anatomical Characters. — In some acute cases, in which the secretion 
has been copious, the lungs do not collapse on opening the thorax, all the 
minute tubes being filled with a frothy fluid. 

The mucous membrane is minutely injected, more or less, throughout 
its whole extent. It is also thickened, generally slightly softened, and 
sometimes contains patches of ulceration, of greater or less extent, and 
the smaller bronchial tubes are found filled with mucus, or purulent 
matter. 

Causes. — Acute bronchitis may arise as a complication in various dis- 
eases, such as asthma, hooping-cough, scarlatina, &c. Or it may be pro- 
duced by irritating inhalations, and various accidental causes. But by 
far the most frequent cause of this disease is cold with dampness, and a 
low electrical state of the atmosphere. And hence it is that bronchitis 
generally occurs during seasons of the year when this state of the atmo- 
sphere prevails. 

Prognosis. — The prognosis in this affection is attended with uncer- 
tainty, for cases that appear to be doing well may suddenly die from 
effusion into and sudden filling up of the small bronchial tubes and air- 
cells. 

A copious and free expectoration of a not too viscid secretion is gene- 
rally a favorable indication, especially if it gradually assumes a yellowish 
color ; thus indicating a termination of the bronchial inflammation. 

Treatment. — From the irritated, congested, and inflamed condition of 
the bronchial mucous membrane, cold extremities, and slight febrile re- 
action, the indications of treatment are readily deducible. 

Warm pediluvia, to encourage the circulation to the extremities, and 
warm sage tea, to promote perspiration, should never be neglected in 
acute bronchitis. Sinapisms should be early and freely applied over the 
chest, as well as the warm infusion of capsicum in vinegar along the 
spine ; the one to counteract internal congestion and overcome the in- 
cipient inflammation, and the other to equalize the circulation as far as 
may be. 

An emetic of antimony or ipecac should be administered, if the patient 
be an adult, but if an infant, or young child, the hive-syrup is prefer- 
able. An emetic helps to equalize the circulation, promotes perspira- 
tion, and helps the secretion of the dry and inflamed mucous membrane, 
and should not therefore generally be omitted. 

With these simple measures, if applied early, the inflammation may 
frequently be arrested, and the patient is convalescent. But if, as too 
often happens, the case is neglected, or improperly treated, at first, the 
symptoms may continue, or become more aggravated. In such cases 
cups should be applied to the chest, and along the spine between the 
shoulders. 

A cathartic of calomel or podophyllin should be administered in castor 
oil, or if the patient be a child, the mercury with chalk may be given 
instead ; after which the bowels may be kept gently loose by mild laxa- 



CHRONIC BRONCHITIS. 455 

tives during the continuance of tha disease. After the operation of a 
cathartic, a blister should be applied to the chest, and kept discharging 
as long as may be consistent with the general strength, or till the in- 
flammation subsides. 

Expectorants are also indicated ; and for children ten drops each of 
hive-syrup and paregoric may be given every four hours, to a child a 
year old. For adults, one-fourth of a drachm of hive-syrup, with ten 
drops each of the tincture of digitalis and stramonium, may be given 
every four hours. 

Towards the termination of the disease, as the bronchial secretion 
assumes a yellowish appearance, half a drachm each of hive-syrup and 
paregoric, with ten drops of the tincture of stramonium, may be given 
every six hours. Mucilage of gum-arabic should be allowed during the 
whole course of the disease, and the patient should be kept on mild, 
digestible, and moderately nourishing diet; and during convalescence 
may take a weak infusion of columbo after each meal. 

SECTION X.— CHRONIC BRONCHITIS. 

We have seen that the mucous membrane of the bronchial tubes are 
liable to acute inflammation, we will now examine chronic inflammation 
of the bronchial mucous membrane, constituting what I have called here 
chronic bronchitis. 

Chronic bronchitis is a very common affection in damp variable 
climates, and during damp and variable seasons of the year, in most 
climates. Aged people are very liable to this affection, with whom it is 
apt to continue for several years, being aggravated during the fall, winter, 
and spring months. But chronic bronchitis is not necessarily confined 
to any age, locality, or season of the year. Only, other things being 
equal, it most frequently occurs in subjects who have been exposed to 
damp, cool, and changeable air, who have been poorly clad, or have 
neglected to keep the stomach, bowels, and skin in a healthy condition. 
In consequence of all this, the mucous membrane of the bronchial tubes 
is liable constantly to become congested, irritated, and inflamed. 

Chronic bronchitis, too, is most liable to occur in persons of broken 
down or impaired constitutions. In fact, a large proportion of the cases 
that have fallen under my observation, during the past twenty years, 
which had been supposed by the patient or friends to be tubercular 
phthisis, were really neglected and protracted cases of chronic bronchitis. 
In some of these cases tubercles have been deposited, and the patients 
have died at last from the combined effects of bronchitis and tubercular 
phthisis. On the other hand, few cases of tubercular phthisis have fallen 
under my observation in which there was not more or less inflammation 
of the bronchial mucous membrane. 

Symptoms. — Chronic bronchitis may be the result of the acute form 
of the disease, but when it is not, it commences with slight uneasiness in 
the chest, with oppressed respiration, accompanied with more or less 
wheezing. There is also slight uneasiness in the epigastrium, loss of 
appetite, a slightly furred tongue, irregularity of the bowels, irritated 
pulse, and generally red and scanty urine. 



456 DISEASES OF THE RESPIRATORY SYSTEM. 

The skin is not much above the natural temperature, but is very dry. 
The cough usually occurs in fits of considerable violence, and is most 
severe on rising from the bed, or on passing into cool damp air, and it 
is also increased by the inhalation of smoke, dust, or even by swallowing. 
Slight transient pains are felt in the chest, in some cases ; but frequently 
there is little uneasiness or pain, except after coughing. 

There is only a slight expectoration, at first, of a glairy mucus, but 
later the matter expectorated becomes opaque, and contains small lumps 
of a viscid, grayish, translucent mucus, which sinks in water. Still later 
the matter often becomes of a yellowish color, and is sometimes streaked 
with blood. The pulse during the early stage is slightly accelerated 
towards evening, and partial sweats are apt to occur about the head and 
breast during the night. There is also considerable thirst, and the urine 
is high colored. 

The cough becomes severe, especially in the morning, and is attended 
with a copious expectoration of a yellowish purulent matter. Debility 
and emaciation follow, and the difficulty of breathing becomes more and 
more distressing. The pulse becomes very frequent, and the face pale 
during the early part of the day, has a deep flush at evening. Profuse 
night sweats usually occur in this latter stage of the disease, and towards 
the termination of fatal cases, diarrhoea and oedema of the ankles are 
liable to supervene, as in the latter stages of phthisis. 

At the very commencement of the disease, the sonorous or else the 
sibilating ronchus is heard on applyiug the ear to the chest, depending 
upon the size of the tubes involved ; but later in the disease, after the 
secretion of mucus has taken place, the mucous or else the sub-crepitant 
rale, or both are heard on applying the ear to the chest. 

In some instances there is gastric or hepatic derangement, either at 
first or very soon after the disease makes its appearance. In such cases 
there is a bitter taste in the mouth, slight tenderness in the epigastrium, 
loss of appetite, a yellow skin, and thirst, with great prostration of 
strength and mental despondency. 

Diagnosis. — To distinguish chronic bronchitis from tubercular phthisis, 
strict attention should be paid to the following differences : In chronic 
bronchitis, the face is pale and the lips of a bluish color, while in tuber- 
cular phthisis the lips are apt to be reddish and the cheeks flushed. 

In chronic bronchitis, the cough is attended with a free expectoration, 
almost from the commencement, while in tubercular phthisis there is 
generally a dry cough for a long time before there is much, if any, 
expectoration. Percussion over the upper part of the lungs elicits a dull 
sound in tubercular phthisis, while in chronic bronchitis the sound on 
percussion is but slightly changed, if at all. 

In the early stages of phthisis, the ear detects a hoarse, harsh, inspira- 
tory sound, and an increased intensity in the expiration, which is also 
lengthened, while in chronic bronchitis, if it be early, there is heard 
either the sonorous or sibilating ronchus; or else, if it be later, the 
mucous or sub-mucous rale is heard on applying the ear to the chest. 

By noticing carefully all these differences, and taking into account the 
history of the case, the hereditary and acquired predisposition and all 
the extrinsic circumstances, the diagnosis between chronic bronchitis and 
tubercular phthisis may be rendered clear and quite certain. 



CHRONIC BRONCHITIS. 457 

Anatomical Characters. — On opening the chest, the lungs do not 
collapse; the capillaries of the mucous membrane of the bronchia are 
very much congested and enlarged, appearing, in some cases, as if the 
membrane was composed mainly of small blood vessels. The mucous 
membrane, besides being congested and thickened, may be either indu- 
rated or softened, or it may contain patches of ulceration, or the mucous 
membrane may be more or less thickly covered with small pimples or 
pustules in some rare cases of a protracted character. 

The minute bronchial tubes besides exhibiting the changes peculiar to 
the larger, are very often more or less gorged with the pulmonary 
secretion. 

Causes. — Chronic bronchitis is very often the result of the acute form 
of the disease. But it may occur from exposure to cold, damp air, or 
from repeated colds, or it may arise as a complication in measles, scar- 
latina, and various other affections. The disease may also be produced 
by the inhalation of irritating particles in the air, and also by the trans- 
lation of rheumatism, erysipelas, and various cutaneous affections. 

Treatment. — In cases of chronic bronchitis in which there is gastric or 
hepatic derangement, as a complication or cause, an occasional blue pill 
should be administered at evening, and pustulation produced over the 
stomach with tartar emetic ointment. But in cases in which there is no 
gastric or hepatic derangement, the indications are to counteract the 
bronchial inflammation, to regulate the functions of the skin and alimen- 
tary canal, to promote expectoration, and finally to restore the tone and 
general strength of the system. 

Dry cups should be applied to the chest at first, and later, blisters 
may be indicated, or pustulation with tartar emetic ointment. Flannel 
should be worn next the skin and the patient should be directed to sleep 
in flannel sheets, and have a warm dry room and an even temperature. 
If the bowels are constipated, a pill of aloes and rhubarb may be given 
after dinner or at evening each day. The patient should take a plain, 
digestible and nourishing diet, and if the blood is weak and the counten- 
ance pale, two grains of the citrate of iron may be given in solution, 
three times per day, and continued for a time to restore the blood. 

To favor expectoration early, one-eighth of a grain of tartar emetic, 
or one-fourth of a grain of ipecac may be given with a teaspoonful of 
syrup of tolu, four times per day; or later, equal parts of hive syrup, 
paregoric and syrup of tolu may be given instead, with ten drops of the 
tincture of digitalis and stramonium if necessary, and continued while 
the cough is troublesome. 

In protracted cases in which there is great debility, ten drops of the 
balsam of Peru may be given, mixed up with a little brown sugar, and a 
teaspoonful of water, four times per day; or ten grains of the balsam of 
tolu may be given instead, made into an emulsion with loaf sugar, gum 
arabic and water; with either of these a little ipecac, tincture of stra- 
monium or tincture of digitalis may be combined as they may be required. 

In cases in which the bronchial secretion has become excessive, con- 
stituting a bronchorrlicea, from five to ten drops of the wood naphtha may 
be given four times per day, mixed with the syrup of tolu or with an 
emulsion of the balsam of tolu or Peru, or whatever expectorant may 
chance to be required. 



458 DISEASES OF THE RESPIRATORY SYSTEM. 

If anodynes become necessary during the continuance of this disease, 
either the stramonium, conium, or hyoscyamus ■will generally do best; 
and in scrofulous cases, the conium I believe should generally be prefer- 
red, as combining an alterative with an anodyne eifect. In cases in 
which there is excessive night sweats, two grains of tannin may be given 
at evening, and the patient should be sustained, especially during the 
stage of debility, by a good, nourishing diet, taken with regularity. 

SECTION XI.— ASTHMA. 

By asthma, I mean that chronic paroxysmal affection characterized by 
great difficulty of breathing, and depending upon a spasmodic constric- 
tion of the larynx, trachea, or bronchial tubes, and attended probably, 
in most cases, with a more or less congested state of their lining mucous 
membrane, which increases the dispncea. 

In order to appreciate the symptoms which are developed in this dis- 
ease, it is necessary to bear in mind the anatomy of the larynx, trachea 
and bronchia ; all of which contain circular muscular fibres, by which 
they may be constricted, and are also lined by a mucous membrane, which 
is liable to become congested. 

These parts, besides being supplied with branches of the spinal and 
great sympathetic nerves, are also supplied by the pneumogastric, which 
nerve, arising from the medulla oblongata, passes along the neck and 
anastomoses with the spinal and sympathetic nerves, and supplies branches 
to the larynx, trachea and bronchia, as well as other surrounding parts ; 
and then passing on to the abdomen, supplies branches to the stomach, 
and to the hepatic, coeliac, gastro-epiploic and solar plexuses. 

Thus we see that the parts involved in asthma are intimately connected 
with, or under the influence of, the sympathetic and cerebro-spinal sys- 
tem of nerves ; and through the pneumogastric are connected directly 
with the respiratory ganglion, the medulla oblongata. 

It will be noticed also that the nervous relation between the respiratory 
passages and the heart, stomach, liver, and other important and vital 
parts, are very close ; accounting for many of the otherwise unaccount- 
able symptoms which attend this disease. 

Symptoms. — In most cases various premonitory symptoms precede an 
attack of asthma ; such as a sense of fullness in the epigastrium, acid 
eructations, headache and general nervous irritability. 

The attack generally occurs during the night, the patient being seized 
with great anxiety, difficult breathing, a feeling of stricture across the 
breast, and a more or less distressing dry cough. These symptoms may 
pass on and acquire a great degree of violence, in which case the breath- 
ing becomes wheezing, laborious, and suffocative ; the countenance is ex- 
pressive of anxiety and distress, and the heart palpitates tumultuously. 
The desire for fresh air is urgent, the patient insists on the doors and 
windows being thrown open, and is generally entirely unable to remain 
in the recumbent posture. The extremities are cool, the face is bloated, 
and livid or pale ; and the veins of the head, neck and face are apt to 
become turgid. The pulse is irregular, intermitting, accelerated, mode- 
rately full and compressible. In some cases, however, it is nearly 
natural. 



ASTHMA. 459 

After these symptoms have continued for a time, the breathing gradu- 
ally becomes less difficult and anxious, and towards morning a more or 
less copious expectoration of viscid mucus generally takes place, and 
there follows some relief of the most distressing symptoms. During the 
day the patient is partially relieved. But as night approaches, the pa- 
roxysm of suffocative breathing returns ; and in this way the disease pro- 
ceeds, with remissions by day and exacerbations at night, for several 
days in succession, before it finally subsides for the time. 

Such, I believe, are the ordinary symptoms of asthma, as it usually 
occurs, involving mainly the bronchial tubes, or lesser air passages of the 
lungs. Asthma sometimes affects, however, the larynx and trachea 
exclusively, or else in connection with the bronchial tubes, several 
marked cases of which have fallen under my observation. 

Laryngeal asthma usually comes on suddenly, like the bronchial, but 
it is not generally attended with as much difficulty of breathing, and 
there is an obstinate, distressing, and almost constant cough, while the 
disease continues. In a marked case of this character that came under 
my observation a few years since, in a middle-aged lady, the cough usu- 
ally came on at evening, and with it the difficulty of breathing, all appa- 
rently depending upon a spasmodic contraction of the larynx, together 
with congestion of its mucous membrane. The cough was usually nearly 
constant during the first night of the attack ; and during the two or three 
succeeding nights, though very troublesome, it grew gradually less, till 
finally the paroxysm would cease after a few days. 

Asthma sometimes assumes a chronic form, the disease continuing on 
for several weeks, with only slight remissions during the day, and exa- 
cerbations at night. The disease in this form is usually attended with a 
troublesome cough, and considerable mucus expectoration. There is also 
considerable difficulty of breathing, and on applying the ear to the chest, 
in such cases, and in fact in all cases of bronchial asthma, a wheezing, 
with "a loud sibilant or dry sonorous rale," may generally be heard. 
In laryngeal cases, however, the abnormal sound is heard in that region, 
and is of a whistling or crowing character, and loud or slight according 
to the degree of narrowing in the laryngeal passage. 

Causes. — Some persons are doubtless hereditarily predisposed to 
asthma. But the disease may arise from a variety of accidental causes ; 
among the most frequent of which are atmospheric viscissitudes, the in- 
halation of irritating particles of matter, the drying up of accustomed 
discharges, the metastatis of rheumatism or gout, masturbation, onanism, 
and excessive venery, plethora, mental emotions, certain kinds of food, 
organic diseases of the heart, spinal irritation, and other like causes. 
And when, the disease is once produced by any one of these, or any 
other cause, its periodical return is probably owing, in part at least, to 
a morbid change, which the first attack or its cause has produced in the 
cerebro-spinal, as well as in the respiratory system. This morbid im- 
pression may be of the brain or spine, or both ; but generally I suspect 
it involves the spine, medulla oblongata, or pneumogastric nerve, as well 
as the respiratory organs, either primarily or secondarily. 

Pathology. — It is evident that in asthma there is spasmodic contrac- 
tion of the larynx, trachea, or bronchial tubes, and it is probable that 



460 DISEASES OF THE RESPIRATORY SYSTEM. 

there is also some congestion of their lining mucous membrane. This 
appears to be the case not only in the laryngeal variety, but also in 
ordinary bronchial asthma, as well as cases in which the disease is con- 
fined to the bronchial tubes of one side. 

Now, in relation to the immediate cause of the spasm in asthma, I 
suspect that the superior portion of the spinal cord, including the medulla 
oblongata, the cervical and pneumogastric nerves, are the parts imme- 
diately involved, in producing the asthmatic paroxysm. 

We have seen that the pneumogastric nerve comes from the medulla 
oblongata, and passing out of the cranium is distributed to the larynx, 
trachea, and bronchia ; and also to the stomach, liver, spleen, pancreas, 
and intestines. Now any local congestion or irritation in that branch 
of this nerve, supplying the larynx, might produce laryngeal asthma, 
while the same or a similar morbid condition of the bronchial branches 
might produce common bronchial asthma, and this may account also for 
the disease being confined in some cases to the bronchia of one lung. 

But in cases in which the morbid change is in the medulla oblongata, 
at the origin of the pneumogastric nerve, the affection may involve the 
larynx, trachea and bronchial tubes. And there will be more or less 
temporary functional derangement of the stomach and other parts sup- 
plied by this nerve, as is the case at the commencement, and during the 
continuance of a paroxysm of many cases of this disease. 

It is probable then that asthma depends upon an irritable condition of 
the cerebro-spinal system, either hereditary or acquired, in consequence 
of which the medulla oblongata, or cervical portion of the spinal marrow 
become the seat of local congestion. This congestion deranges the flow 
of nervous influence through the pneumogastric and cervical nerves, and 
very likely produces the spasmodic and other symptoms which arise in 
this affection. . 

Prognosis. — Asthma seldom terminates fatally. But if the disease 
is severe and protracted, it indicates a serious chronic derangement of 
the cerebro-spinal system, and it may eventually lead to pulmonary dis- 
ease of a serious and dangerous character. 

Treatment. — At the commencement of an attack of asthma the feet 
should be placed in warm water, and dry cups applied to the back of 
the neck, or along the cervical portion of the spine. This will sometimes 
arrest the approaching paroxysm, but not always. 

If the attack be very severe, an emetic of ipecac or of the compound 
syrup of squill may be administered. And if the hive-syrup be used, a 
tablespoonful may be given every fifteen minutes till free vomiting is pro- 
duced. After the vomiting when it is indicated, and in all cases in which 
vomiting is not indicated, the hive-syrup and tincture of lobelia, of each 
half a drachm, with twenty drops of the tincture of stramonium may be 
given every six hours, and continued during the continuance of the 
paroxysm. 

If the patient is decidedly plethoric, and the congestion of the spine 
very marked, two or three ounces of blood may be taken by cups from 
the back of the neck, or along the cervical portion of the spine. And 
in case there is much spinal irritation, a stramonium plaster may be ap- 
plied along the spine between the shoulders, during a paroxysm of either 
laryngeal or bronchial asthma. 



HOOPING-COUGH. 461 

If the bowels are confined during an attack of asthma, a cathartic of 
the sulphate of magnesia, rhubarb, leptandrin, or castor oil may be ad- 
ministered. And to prevent a return of the asthmatic paroxysm, or to 
break up the asthmatic tendency in the system, it is necessary to remove 
any cause that may have been operating to produce it, and to insist upon 
a strict observance of the laws of health in every respect. 

Cups may be applied occasionally to the back of the neck, or cups or 
blisters may be applied along the cervical portion of the spine, and any 
general derangement of the system may be corrected by proper remedial 
measures as far as may be. If there is a debilitated condition of the 
system, and a weak state of the blood, the citrate or carbonate of iron 
may be given, and continued till a healthy condition of the blood is re- 
stored. 

If there is a rheumatic or gouty condition, or derangement of the 
glandular and lymphatic system, the iodide of potassium may be given 
in five grain doses, three times per day, and continued for several weeks. 
If both an alterative and tonic are indicated, the syrup of the iodide of 
iron may be given in ten drop doses, three times per day; after discon- 
tinuing the iodide of potassium, or in cases in which that is not required. 

By thus removing the cause, restoring the blood, correcting the general 
condition of the system, and subduing spinal irritation; the irritability 
of the cerebro-spinal system, may in some cases be so far overcome, as 
to arrest the congestive tendency, and thus a permanent cure may be 
effected. 

SECTION XII.— HOOPING-COUGH— (Pertussis.) 

By hooping-cough, or pertussis, I mean that peculiar contagious dis- 
ease, attended with a spasmodic cough, which has its regular rise, progress, 
and declension ; destroying in the system, the susceptibility to a second 
attack of the disease. 

Symptoms. — Hooping-cough generally commences very much like an 
ordinary cold ; the patient experiencing a degree of lassitude, headache, 
slight hoarseness, sneezing, and more or less oppression, or difficulty of 
breathing. The sleep becomes disturbed, the appetite is weak, the bowels 
are torpid, and the pulse indicates slight febrile excitement towards 
evening, in some cases. 

For the first two or three weeks, the cough is dry and ringing, and the 
paroxysms are short, and there is not that peculiar sound, called whooping, 
which attends the disease as it progresses. About this time, however, 
the cough assumes a more spasmodic character; the paroxysms coming 
on more frequently, and are generally of longer duration. 

The inspirations, during a fit of coughing are difficult, slow, and at- 
tended with a sense of spasmodic stricture of the glottis, rendering the 
paroxysms suffocative, and more or less convulsive. The approach of a 
paroxysm is preceded by a feeling of tightness in the breast, and titil- 
lation in the larynx, and after continuing for five or six minutes, the 
paroxysm terminates, with the expectoration of a viscid mucus. Some- 
times the paroxysm of coughing terminates by vomiting, in which case 
the patient generally experiences some relief. There is also considerable 



462 DISEASES OF THE RESPIRATORY SYSTEM. 

congestion of the brain, in some cases, and occasional bleeding from the 
nose. 

The disease usually continues on in this aggravated form four or five 
weeks, when it begins to abate, the declension being gradual, and occu- 
pying three or four weeks ; making the duration of the disease, including 
the three stages, about three months. The disease is liable, however, to 
variation in this respect, the duration being in some cases longer, and in 
others, shorter than the period mentioned above. In some simple un- 
complicated cases of hooping-cough, there is little or no fever. If, 
however, local inflammations arise, there is apt to be more or less irregu- 
lar febrile excitement. 

Hooping-cough is highly contagious ; generally occurs during child- 
hood, and it may prevail epidemically, being favored, no doubt, by cer- 
tain epidemic or endemic influences. 

Prognosis. — Simple, uncomplicated hooping-cough rarely terminates 
fatally. But there is always a liability of the supervention of hydro- 
cephalus, bronchitis, pneumonia, laryngitis, tracheitis, apoplexy, &c, in 
consequence of which the disease may have a fatal termination. And 
besides, various diseases are liable to follow this affection, such as dropsy, 
ophthalmia, deafness, paralysis, and phthisis pulmonalis. 

Cause. — This disease is produced by a peculiar contagion, which is 
generated in the system while laboring under the affection, the disease 
first having had its origin in some species of imprudence, as is the case 
with all contagious diseases to which the human family are now liable. 
This disease does not appear capable of communicating itself till it has 
continued two or three weeks, and then the contagion does not appear 
to extend far from the body of the affected person. 

Besides, a specific contagion, which I believe is the general, if not the 
invariable cause of this disease, it is probable, as we have seen, that 
various epidemic and endemic influences favor the production and spread 
of this disease. 

Anatomical Characters. — The bronchial tubes may be found dilated, 
and they are generally found filled with a "viscid muco-purulent fluid." 
There is also in many cases marks of a cerebral congestion, and various 
other morbid appearances, the result of complications which arise during 
the continuance of the disease, rather than marks of the disease itself. 

Nature. — It appears probable that the contagious principle received 
into the blood, produces its impression upon the cerebro-spinal and nerv- 
ous system, and that the primary seat of the local irritation thus set up, 
is the cervical portion of the spinal chord, or the medulla oblongated, or 
both, in consequence of which the pneumogastric nerve becomes involved, 
and also the phrenic, together with the cervical nerves with which they 
are more immediately connected. 

This will account for all the symptoms essential to this disease, and 
also, as far as may be, for the local inflammations which arise, only a 
slight accidental cause being sufficient to develop them in parts in 
which there is already irritation with marked nervous derangement. 

It is a little interesting to reflect that a contagious principle should 
produce its local impression in this manner, and after continuing foe a 
few weeks, should gradually subside, and thus destroy the suscepti- 



TUBERCULAR PHTHISIS. 463 

bility of the system to the morbid impression "which the poison was be- 
fore capable of producing. But the part involved doubtless undergoes 
a change by which its structure is materially fortified against the effects 
of a like agent, even though it be introduced into the system in all its 
freshness at some subsequent period. Hooping-cough, however, in de- 
stroying the susceptibility of the system to a second attack, is following 
in the train of many other contagious diseases, thus furnishing a strong 
evidence of its genuine contagious character. 

Treatment, — If this is the real nature of hooping-cough, it is not 
strange that it should be affected but slightly, if at all, by medical treat- 
ment, at least in its simple form, and such I believe is generally the 
case. 

I would therefore do nothing for a simple uncomplicated case of hoop- 
ing-cough, except to regulate the diet, and perhaps apply cups to the 
back of the neck, blisters along the cervical portion of the spine, and 
later, a stramonium or belladonna plaster between the shoulders, all 
with a view of lessening the irritation of that portion of the spinal mar- 
row, and also of the pneumogastric, phrenic, and cervical nerves. 

If, however, hooping-cough becomes complicated with bronchitis, 
pneumonia, or any other local inflammation, the patient should be 
treated as ordinarily for such affections, taking into account, of course, 
the general condition of the system. If, as sometimes happens with 
young children, there is some bronchial irritation, and the secretion 
threatens suffocation, an emetic of ipecac may be given for the purpose 
of throwing off the secretion. 

In cases in which an emetic is not required, and the bronchial irrita- 
tion requires an expectorant, five drops each of the hive-syrup and tinc- 
ture of lobelia, with a drop of the tincture of stramonium may be given 
every six hours, to a child one year old. The patient with hooping- 
cough should take a plain digestible diet, with regularity, should be com- 
fortably clad, and on no account should he be exposed to cool damp air. 

SECTION XIII.— TUBERCULAR PHTHISIS— (Consumption.) 

By tubercular phthisis, I mean that peculiar constitutional disease, 
either hereditary or acquired in which with a general depraved condition 
of the system, there is derangement of the lymphatic and glandular sys- 
tem, poverty of the blood, and irritation with tubercular deposit in the 
larynx or lungs, or both. 

This disease is strongly hereditary, and is doubtless the result of the 
various imprudences practiced by the human family, the effects of which 
have accumulated, and rendered imperfect the various tissues and organs 
of the body, in consequence of which the various functions are illy per- 
formed, and especially digestion and assimilation. 

Now in a person strongly predisposed, a very slight imprudence ; or 
long continued imprudence in those not especially predisposed, may serve 
to bring about the scrofulous or tuberculous diathesis, or a depraved con- 
dition of the system, with impaired digestion and assimilation, derange- 
ment of the lymphatic and glandular system, and more or less poverty 
of the blood. When this scrofulous condition of the system exists, either 



464 DISEASES OF THE RESPIRATORY SYSTEM. 

from hereditary or accidental causes, or from both, the fat and albumen 
of the chyle in passing through the mesenteric glands are not converted 
into fibrin as perfectly as in health, and hence the integrity of the blood 
is more or less impaired, there being in most cases an accumulation of 
albumen. 

Besides, in this scrofulous condition, the lymphatic system, including 
the lymphatic vessels and glands, are more or less deranged. And as 
the lymphatics take up in health the albuminous matter which transudes 
from the blood-vessels, as well as that liberated by changes going on in 
the tissues, and in passing it through the lymphatic glands, converts it 
into fibrin, this process is more or less interrupted, thus causing a further 
derangement in the blood, and especially an accumulation of albuminous 
matter. 

Now this condition constitutes, as I believe, the tubercular diathesis, 
and it may continue for a long time without any tubercular deposit tak- 
ing place, and by prudence, proper care and treatment, the condition 
may be overcome and tolerable health restored. But more frequently 
this scrofulous or tubercular diathesis continues till some tissue or organ 
becomes weakened, irritated or inflamed, and then it becomes the seat of 
tubercular deposits, and the blood disposes of its retained or accumulated 
albuminous and other matters. 

The alimentary canal, kidneys, liver, and every tissue and organ of 
the body may be the seat of this tubercular deposit, depending very much 
on some slight accidental condition, such as congestion, irritation, or in- 
flammation. Or the deposit may take place in a part from debility, re- 
laxation, or some other accidental cause. 

But if, as is often the case, the larynx or lungs, or both, are predis- 
posed to tubercular deposit, only a slight exciting cause such as relaxa- 
tion, congestion, irritation, or inflammation may lead on to the tubercular 
deposit in the larynx or lungs, constituting laryngeal or pulmonary con- 
sumption, or both, as is often the case. 

If the tubercles are deposited in the larynx, they are either in, or im- 
mediately under the mucous membrane, in the submucous cellular tissue. 
If the lungs be the seat of the tubercular deposit, they are generally 
first deposited between the arteries, veins, air-cells and bronchial tubes, 
in the upper part of the lungs, and filling up the cellular tissue which 
connects these parts, in the form of miliary tubercles, gray tuberculous 
infiltration, gelatinous infiltration, or yellow tuberculous infiltration, they 
produce pressure on the bronchial tubes, and thus in the early stage of 
the disease, cause a dry cough, and many other symptoms which arise. 

As we have now seen in what the tubercular diathesis consists, and the 
manner in which the deposit takes place, we will now proceed to examine 
the symptoms which arise in laryngial and pulmonary phthisis, and first 
of the laryngeal variety. 

Symptoms. — Laryngeal consumption generally occurs in connection 
with pulmonary, but it may exist independent of pulmonary disease. It 
is most liable to occur in persons who have been exposed to particles of 
dust, which has served to irritate the laryngeal mucous membrane, and 
has thus led on to this form of tubercular disease. 

There is generally a degree of fullness experienced in the fauces and 



TUBERCULAR PHTHISIS. 465 

larynx, with slight soreness, early, in some cases, but with little or none, 
at first, in others. A slight cough too frequently occurs, long before 
the tubercular deposit commences, in consequence of the irritation. But 
as the tubercles become formed, in and under the laryngeal mucous mem- 
brane, they produce mechanical obstruction to the respiration, and also 
a tickling sensation, which produces a dry, hoarse cough. 

This cough is increased by exposure to dust, or to cold air, and re- 
mains dry till the tubercles soften, or a secretion occurs in the larynx. 

Hoarseness of the voice is one of the characteristic signs of laryngeal 
phthisis, beginning at the very commencement of the disease, and con- 
tinuing generally to its termination. In some cases there is an entire 
loss of voice, in consequence of the narrowing of the laryngeal passage, 
and change in the vocal chords. 

If the ear be placed over the larynx, during the early stage, a wheez- 
ing, crowing, or whistling sound is distinctly heard. Later, after soften- 
ing of the tubercles has commenced, or a mucous secretion has taken 
place, the air in passing through the tubercular or mucous matter pro- 
duces a gurgling noise, or the tracheal rattle, which is readily heard on 
applying the ear to the larynx. 

There is little or no febrile action in this disease, except that which 
comes on in the latter stages, in consequence of prostration of the gene- 
ral powers of the system, and this is of a peculiar hectic character. The 
appetite may be tolerable, but digestion and assimilation is defective, 
and the system sinks rapidly under the constitutional and local disease. 

Such are the ordinary symptoms of laryngeal consumption, when it 
exists independent of pulmonary disease. But it often exists in connec- 
tion with pulmonary phthisis, the symptoms of which we will now pro- 
ceed to consider. 

In pulmonary, as in laryngeal phthisis, the general powers of the sys- 
tem, as we have seen, are always weakened ; the lymphatic and glandular 
system deranged ; and the blood is in a depraved or unhealthy state. 
The countenance is therefore at the commencement of this disease gene- 
rally pale, with a slight flush towards evening ; the nerves are irritable, 
and the pulse frequent ; and there may be a slight cough, even before 
the tubercles are deposited, but not necessarily, unless the disease fol- 
lows chronic bronchitis. As the tubercular deposit commences in the 
cellular tissue in the upper part of the lungs, of whatever form they may 
chance to be, they press upon the smaller bronchial tubes in the vicinity, 
and by provoking a mechanical irritation, produce a dry cough, which 
gradually increases as the tubercles accumulate. 

At this stage, percussion elicits a dull sound in the upper part of the 
chest, on one or both sides, and if the ear be applied to the part, the 
sonorous ronchus is sometimes heard in consequence of the narrowing of 
the bronchial tubes, from mechanical pressure. And there is also a 
slight interruption or jerking, in the inspiration, and a lengthening or 
prolongation of the expiratory sound, caused by the interruption to the 
free passage of air through the compressed bronchial tubes. 

After a longer or shorter time, the tubercles will have so far accumu- 
lated, as to form a serious impediment to respiration, at least in one of 
the lungs. And the pressure of these tubercles, together with the irri- 
30 



466 DISEASES OF THE RESPIRATORY SYSTEM. 

tation of the parts set up by the coughing, produces local irritation, and 
sometimes slight inflammation jn the parenchyma of the lungs, and also 
in the adjacent bronchial tubes. 

Now this irritation, or inflammation of the pulmonary tissue, is atten- 
ded or followed by slight oedema of the parts involved, and consequent 
softening of the tubercular deposit. And the matter which results from 
the softening of the tubercles, becomes mixed with a little serous and 
purulent matter, which accumulates in consequence of the surrounding 
inflammation, and thus a collection of matter is formed in the lungs, 
between the bronchial tubes, with no way of escape, at first, into these 
tubes. 

Generally about this time, there is a slight effusion into the bronchial 
tubes, in consequence of bronchial irritation or inflammation; so that 
though there still remains dullness on percussion over the part, as at the 
first; a slight muco-crepitant, or sub-crepitant rale is produced by respi- 
ration, and may be distinctly heard, on applying the ear to the part. 
In cases, however, in which the smaller bronchial tubes become greatly 
obstructed, there is the sound of air passing through the larger bronchial 
tubes, constituting the tubular breathing, or bronchial respiration. 

The sounds of the heart, are generally more audible in the early stages 
of phthisis, than in health, and there is also an increase in the vocal 
resonance, as well as in that of the cough, as might be expected from 
the condition of the parts. 

Sooner or later, the collection of albuminous, serous, and purulent 
matter, resulting from the softening of the tubercles, and the surround- 
ing inflammation, produces an ulceration of the adjoining bronchial tube, 
or tubes; and bursts into their cavity, and thus an albuminous sero-puru- 
lent matter begins to be expectorated. Sometimes more or less blood is 
mixed with this matter, in consequence of rupture of one or more small 
vessels, in the immediate vicinity of the cavity. If the ruptured vessel 
be large, the hemorrhage is sometimes very copious, and even dangerous. 

As the matter becomes expectorated the affected side of the chest 
may become sunken, and inspection detects also a diminished respiratory 
movement. The sound on percussion' may remain dull for a time, but 
as the cavity acquires considerable capacity, the sound elicited by per- 
cussion may be resonant, or even tympanitic. 

Auscultation at this period detects the cavernous rale, or a gurgling, 
as well as a cavernous resonance of the voice and cough, which are pro- 
duced by the passage of air into the cavity, which contains more or less 
fluid, as the secretion or formation of matter is constantly going on. If 
the cavity becomes large there may be the amphoric breathing, the 
voice may acquire the amphoric resonance, and the bursting of bubbles 
into the cavity may produce the metallic tinkling, all of which may be 
detected by applying the ear over the affected part. 

Should it become desirable to note more particularly than can be 
done by inspection, the degree of diminution in the capacity of the 
affected lung, it may generally be very conveniently done by means of a 
tape passed round the chest, or, if at hand, the spirometer of Mr. Huch- 
inson, or other instruments which have been invented for the purpose, 
may be a convenience. 



TUBERCULAR PHTHISIS. 467 

Finally, in cases in which there is a large cavity in the lung, some 
additional idea of its capacity may often be obtained by succussion, 
which, if skillfully performed, produces, as we have seen, a sound similar 
to that caused by shaking a cask which contains air and a fluid. 

Such are the ordinary symptoms developed during the progress of 
pulmonary phthisis. But as the cough and expectoration continues the 
general strength wastes away, and great emaciation takes place. The 
pulse becomes weak and very frequent, the countenance acquires a hectic 
flush, night sweats follow, the feet and limbs become oedematous, and 
finally, if not taken off" by hemorrhage, a diarrhoea supervenes, and the 
patient dies ultimately from exhaustion. 

Such, then, is the general course and termination of tubercular phthisis, 
the greatest scourge of the human family. And as it is the result of the 
combined or accumulated imprudence of mankind, it is too often the 
stern defier of our best directed efforts at relief, and sweeps off not only 
those who have disregarded the laws of health, but also those upon 
whom "the iniquities of the fathers have been visited," in accordance 
with the direct declaration of the Almighty. 

Anatomical Characters. — The post-mortem reveals either the miliary 
tubercles, tuberculous infiltration, gelatinous infiltration, or the yellow 
tuberculous infiltration, as well as signs of inflammation, and cavities of 
greater or less capacity, occupying generally the upper part or summit 
of the lung. 

Generally the pulmonary and costal pleura are found adhering, and 
in addition to tubercles, cavities, and signs of inflammation of the affected 
lung or lungs, the bronchial tubes are found dilated, and the bronchial 
glands are often more or less enlarged and indurated. Tubercles are 
also found in the pleura, peritoneum, intestines, mesenteric glands, liver, 
spleen, testicles, brain, and lymphatic glands ; and they may be found 
in any tissue of the body, even in the bones. 

The mesenteric glands are often enlarged, and show signs of having 
been inflamed. And the stomach and intestines are found to have under- 
gone more or less organic change, generally presenting more or less ex- 
tensive ulceration along the mucous membrane. 

Diagnosis. — To distinguish tubercular phthisis from chronic bronchitis 
it is only necessary to take into account the general features and history 
of the case, and to note carefully the following differences. 

In tubercular phthisis, though there be paleness, the cheeks are flushed 
at times, and the lips are apt to be reddish, while in chronic bronchitis 
the face is pale, and the lips are apt to be of a bluish color. 

In tubercular phthisis there is generally a dry cough for a long time, 
before there is much, if any, expectoration, while in chronic bronchitis 
the cough is attended with a free expectoration, almost from the first. 
Percussion elicits a dull sound in the upper part of the chest, in tuber- 
cular phthisis, while in chronic bronchitis the sound on percussion is but 
slightly changed, if at all. In the early stages of phthisis the ear 
detects a hoarse wavy inspiration, and an increased and prolonged expi- 
ration, while in chronic bronchitis, if it be early, there is heard either 
the sonorous or sibilating ronchus, or else, if it be later, the mucous or 
submucous rale is heard, on applying the ear to the chest. 



468 DISEASES OF THE RESPIRATORY SYSTEM. 

By noting carefully all these differences, and taking into account the 
history of the case, the predisposition, hereditary or acquired, and weighing 
carefully all the extrinsic circumstances, the diagnosis between tubercular 
phthisis and chronic bronchitis may be rendered clear and certain. 

Tubercular phthisis need not be confounded with pneumonia, or any 
other pulmonary affection, if all the symptoms be carefully taken into the 
account. And the presence of tubercles in the larynx, may generally 
be clearly inferred by the peculiar symptoms, already laid down, which 
they develop. 

Causes. — The predisposition to tubercular phthisis may be inherited, 
or it may be acquired by various abuses of the system, such as habits of 
filth, improper or unwholesome food, irregularity of taking food, insuffi- 
cient clothing, masturbation, and excessive venery, the use of tobacco, 
gluttony, drunkenness, licentiousness, and other like abuses. 

A strong hereditary or acquired predisposition to tubercular phthisis 
may exist, and yet by a careful return to a strict observance of the laws 
of health, and avoiding the exciting causes, the local tubercular disease 
may never be developed. More frequently, however, some accidental 
exciting cause is brought to bear, and tubercles are deposited, either in 
the larynx or lungs, or both. 

Among the exciting causes of this disease, gastric and hepatic derange- 
ment, with pulmonary or bronchial irritation, are probably the most fre- 
quent. But there are various exciting causes of tubercular phthisis, such 
as cool damp apartments, the depressing passions, the inhalation of irri- 
tating vapors, or fine particles, into the larynx and lungs, losses of blood, 
the healing up of old ulcers, suppression of the menses, the retrocession 
of cutaneous affections, the use of tobacco, self-pollution, venereal ex- 
cesses, licentiousness, and various kindred abuses of the system. 

Various diseases also tend to develop tubercular phthisis, in those who 
are predisposed, such as measles, scarlatina, hooping-cough, small-pox, 
and various inflammatory affections. Females are more subject to the 
disease than males. And the disease occurs most frequently, in both 
sexes, between the ages of twenty and thirty years, at least according to 
my observation. 

Prognosis. — The prognosis in tubercular phthisis, whether laryngeal 
or pulmonary, is decidedly unfavorable. The only hope in laryngeal 
cases must be confined to the early stage, for if the tubercles begin to 
soften, or ulceration takes place in the larynx, little hope need be enter- 
tained of a favorable termination of the case. 

Tubercles may be deposited in the lungs, however, and yet, if they are 
not sufficiently numerous to produce mechanical irritation, no softening 
need necessarily take place if the system be brought into a healthy con- 
dition by a rigid observance of the laws of health and proper remedial 
measures. So, too, it is probable that a small collection of tubercles 
may soften and be thrown up and the cavity cicatrize, contract down and 
heal, if the blood and general condition of the system can be restored to 
a healthy state. Finally, if a small collection of tubercles have softened 
and been expectorated, and a small cavity formed, there is a bare pos- 
sibility, if the general condition can be improved, that the cavity may 
contract, and if it does not heal, that the membrane which lines it may 



TUBERCULAR PHTHISIS. 469 

so far assume the character of a mucous membrane as to cease to be a 
secreting surface, and thus a tolerable cure be effected. 

With a bare possibility of either of these results, no time should be 
lost in correcting the habits of the patient, and in resorting to the use of 
such measures as are indicated, to effect a cure, if that is possible, and to 
allay and palliate, as far as may be, if a cure is impossible, as is generally 
the case. 

Treatment. — The general treatment proper in tubercular phthisis is 
such as -will tend to restore the blood, improve digestion and assimilation, 
and correct the general depraved condition of the system. The patient 
should be directed to take a reasonable amount of exercise in the open 
air, either by walking, riding on horseback, or otherwise, as the pecu- 
liarity of the case may appear to require, and the condition tolerate. 

The patient should be warmly clad ; should always wear flannel next 
the skin, and should be directed to sleep in flannel sheets ; great care 
should also be taken to keep the feet warm and dry and to avoid damp 
cool air. 

A large sleeping room in the upper story should be preferred to sleep- 
ing in the lower part of the house, and if it can be immediately under 
the roof, or near it, the better still, as the heat of the sun will tend to 
dry the air, especially if the room be on the south side of the house, 
which is always desirable. 

The patient should be directed to wash the surface of the body at least 
once each week in summer, and once in two weeks in winter, with 
tepid water containing a little salt, to keep the skin clean and in a 
healthy state. 

The diet should be regulated to suit the condition of each particular 
case. It should generally be of a digestible and nourishing character, 
or as much so as the stomach will bear and digest well. Milk, in most 
cases, with good wheat bread and a little meat will do very well and is 
generally very acceptable to the patient. The food should be taken with 
strict regularity and on no account should any be taken between meals, 
as it always tends to impair digestion. 

Having regulated the exercise, clothing, diet and habits of the patient, 
some preparation of iron should in most cases be administered. In de- 
cidedly scrofulous cases, with considerable prostration, the syrup of the 
iodide of iron may be given in ten drop doses in a wine-glass of water, 
three times per day before eating, and continued for a long time. The 
iron in this preparation may improve the blood, and the iodine may act 
favorably on the lymphatic and mesenteric glands, which are always more 
or less deranged in such cases. 

In decidedly anaemic cases, in which the glandular derangement is 
less marked, the carbonate or citrate of iron may do best. If the car- 
bonate is used, it may be given in three grain doses three times per 
day, and if not contra-indicated, it may be given in a teaspoonful of 
Madeira wine and molasses of each equal parts. To four fluid ounces each 
of the wine and molasses, three drachms of the iron may be added, and 
a teaspoonful of the mixture may be given, after thoroughly shaking, 
three times per day. 

If the patient is anaemic, and still a stimulant is contra-indicated, the 



470 DISEASES OF THE RESPIRATORY SYSTEM. 

citrate of iron may be the best preparation, given in two grain doses in 
solution, immediately before or after eating. Or what would do better 
still, during meals, that it may mingle with the food, and so pass with 
the chyle to the blood. 

In cases in which there is a decided dropsical or hemorrhagic ten- 
dency, the tincture of chloride of iron is the best preparation, and 
should be given in ten drop doses three times per day, in a wine-glass of 
water. In dropsical cases, or in cases in which there is enlargement or 
induration of the lymphatic or mesenteric glands, five grain doses of the 
iodide of potassium may be given in a fluid ounce of simple syrup, three 
times per day, before each meal, and continued for a time. 

In all cases of tubercular phthisis, in which the digestion and assimila- 
tion is such, that the patient begins to emaciate, whether much or little 
food be taken, the cod-liver oil should be given, in tablespoonful doses, 
three times per day, an hour after each meal, and if it agrees with the 
stomach and bowels, should be continued while its effects appear salutary.* 
Together with this general treatment, in the early stage, dry cupping, 
blisters, or pustulation, with tartar emetic ointment, may be required, i 

If the larynx is the seat of the tubercular deposit, a blister should be 
applied early over the larynx, and it may be repeated if necessary ; or 
pustulation may be produced by tartar emetic ointment, if the patient 
can bear it. After counter-irritants have been carried as far as prudent, 
an ointment of the iodide of potassium, two drachms to the ounce of 
lard, may be continued over the larynx. And a solution of two drachms 
of the iodide of potassium to the ounce of water, applied' to the fauces 
and laryngeal cavity, every other morning for a time, and later, once or 
twice per week. It may be conveniently done, and as I have found, 
with very little disturbance to the patient, by means of the instrument 
recommended by Dr. H. Green, of New York, consisting of a bent 
whalebone, to the end of which is firmly fastened a soft piece of sponge. 

After having applied the solution of the iodide of potassium for a 
time, as I have done, if the hoarseness is less, but considerable irritation 
or ulceration of the laryngeal mucous membrane continues, a solution of 
the crystals of nitrate of silver, of the strength of from forty to fifty 
grains to the ounce of water, may be substituted for the iodide of potas- 
sium, and applied as practiced by Prof. Green, every other day, at first, 
and later, two or three times per week, while any hope of relief remains. 

While I am not certain that I have ever cured a case in which tuber- 
cles were actually deposited, by this treatment, I am confident that I 
have greatly palliated or retarded very bad cases, and believe that in- 
cipient cases may sometimes thus be permanently cured, if the general 
condition of the patient is at the same time restored or corrected. 

If the lungs are the seat of the tubercular deposit, dry cups may be 
applied occasionally, at first, and then blisters, or pustulation may be pro- 
duced by tartar emetic ointment. And after the counter-irritants have 
been continued as long as is prudent, or necessary, the compound iodine 
ointment should be applied to the upper part of the chest. A drachm 
each of iodine and iodide of potassium may be dissolved in a little water, 
and then mixed with an ounce of lard. This may be applied morning 

* The hypophosphites may be of service in some eases. 



APNCEA. 471 

and evening, so that half an ounce may be used per week, as long as 
there is any hope of relief. 

As a gentle tonic and sedative in tubercular phthisis, the wild-cherry 
bark, the primus virginiana is a valuable remedy in all stages of the 
disease. A wine-glassful of the officinal infusion may be given, three or 
four times per day, in all cases in which a gentle tonic, and sedative is 
required. And it may safely be continued, if necessary, for a long time. 

Should expectorants be required in the early stage, in consequence of 
bronchial irritation; a teaspoonful of the syrup of tolu, with one-fourth 
of a grain of ipecac, or one-eighth of a grain of antimony may be given, 
four times per day, as an expectorant and diaphoretic. Or as the disease 
progresses, a teaspoonful of a mixture of equal parts of hive-syrup, and 
paregoric, with ten drops of the tincture of digitalis, may be given, four 
times per day, instead, and continued while it soothes the cough, or favors 
expectoration. 

If, however, there is a hemorrhagic tendency, the best expectorant is 
the balsam of Peru, in ten drop doses, with one-fourth of a grain of 
ipecac, mixed with a little brown sugar and water; and given four times 
per day, with ten drops of the tincture of digitalis, in case the pulse is 
active, or very frequent. 

In cases in which there is an excessive secretion, and expectoration, 
and in part the result of a bronchorrhoea, the wood naptha may be in- 
dicated, and should be given in five drop doses, in a teaspoonful of the 
syrup of tolu, four times per day, till the secretion is checked. 

For the night sweats, if attended with a diarrhoea, two grains of tan- 
nin may be given, at evening, and repeated once or twice during the 
night, if necessary. In case this fails to check the sweats and diarrhoea, 
ten drops of the aromatic sulphuric acid may be given, three times per 
day, with a drachm of the fluid extract of blackberry, the rubus villosus 
generally with very good effect. 

Now, by thus carefully correcting the habits, and general condition of 
the consumptive patient, and bringing them in every respect into a strict 
observance of the laws of health, many cases may be retarded, at least, 
and some cases may very likely, be permanently arrested, if only in the 
incipient stage. 

If, however, the disease has passed the stage, at which it may be ar- 
rested ; a wise and prudent return to the laws of health, will have a good 
effect upon the morals of the patient, and may retard more or less, the 
progress of the disease. And by resorting to just so much medical 
treatment, as is clearly indicated, and nothing more, the patient may live 
on in comparative comfort, for months or even years ; and finally be 
gently soothed down through the " dark valley of the shadow of death," 
by a kind and prudent medical hand. 

SECTION XIV.— APNCEA— {Asphyxia.) 

By apnoea, I mean absence of respiration, or of that which is sensible, 
a condition sometimes designated by asphyxia, which means literally a 
want of pulse. 

Respiration may be suspended by a great variety ef causes, some of 



472 DISEASES OF THE RESPIRATORY SYSTEM. 

which act by preventing the access of air to the lungs, as smothering, 
submersion, strangulation, &c. Others act by affecting the air respired, 
as the irrespirable gases, such as carbonic acid, nitrogen, hydrogen, &c. 
And others still, produce paralysis of the muscles concerned in respira- 
tion, by affecting the medulla oblongata, or spine above the origin of the 
phrenic nerve, as electricity, hanging, &c. 

I shall, however, refer only to those of a practical importance, in- 
cluding apnoea from drowning, from strangulation, from irrespirable 
gases, from electricity, and from cold. And, as a matter of convenience, 
shall consider each, with the treatment proper, separately, in the present 
section; and first, apnoea from drowning. 

APNCEA FROM DROWING. 

When a body is first taken from the water in which it has been sub- 
mersed till the manifestations of life are extinct, the face has a turgid 
and livid appearance, the eyes are open and staring, the tongue is thrust 
beyond the teeth, the limbs are stiff, and there is generally a fullness of 
the epigastrium. 

Death occurs from submersion by the exclusion of atmospheric air 
from the lungs, in consequence of which the blood does not receive oxy- 
gen or throw off carbonic acid. The venous blood in such a case passes 
from the extreme pulmonary arteries into the minute pulmonary veins. But 
as the presence of arterial blood is essential to a healthy action of the pul- 
monary veins, the pulmonary circulation is interrupted. And as a con- 
sequence of this interruption to the pulmonary circulation, venous blood 
accumulates, and congestion takes place in the pulmonary arteries, in the 
right cavities of the heart, in the large veins, and also in stomach, 
liver, spleen, and intestines, and there is, in fact, a general venous en- 
gorgement. While the venous system, the right cavities of the heart, 
and the pulmonary arteries, are thus gorged with blood, there is not suffi- 
cient venous blood reaching the left cavities of the heart, to stimulate 
them to action. And besides, it is probable that the little venous blood 
which does reach the left side of the heart, on entering the arteries of 
the heart, may tend to impair its powers ; and should a small portion of 
it reach the brain, or other parts of the system, it could scarcely fail to 
smother, rather than sustain vitality. 

It is a fact now well understood, that the regular transmission of arte- 
rial blood to the brain is indispensible to the healthy performance of its 
functions. It appears to me, then, that one of the first effects of sus- 
pended respiration, towards the destruction of vitality, is a cessation of 
cerebral action, for want of a supply of arterial blood. 

As the cerebral functions are suspended, the want of a sufficient sup- 
ply of nervous influence to the animal functions causes their suspension. 
And as the ganglionic system derives its power to act from the brain, 
there is very soon a suspension of the vital functions. Vitality may, 
however, linger for some little time after most of the phenomena of life 
have disappeared. 

It as a matter of doubt how long a person may remain under water 
in a state of apnoea, and yet have sufficient vitality remaining to afford a 
chance of being resuscitated by proper restorative measures. 



APNCEA. 473 

It is probable, however, that resuscitation may sometimes be produced 
after submersion for fifteen or twenty minutes, and perhaps longer. 

If the water is warm, it is probable that vitality may remain longer 
than if the water is cold. And there is doubtless a difference in indi- 
viduals as to their respective powers of vital resistance, under similar 
circumstances of submersion. 

Morbid Appearances. — The morbid appearances presented on the dis- 
section of persons who have died by drowning, are a general venous 
turgescence, and especially congestion of the pulmonary arteries, right 
cavities of the heart, and of the larger venous trunks. 

The pulmonary veins, the left cavities of the heart, and the arteries 
generally, are comparatively empty. There is considerable vascular 
congestion of the brain, but very rarely so much as to justify the belief 
of an apoplectic condition, as the cause of death. The blood in most 
cases is either fluid or imperfectly coagulated, especially if death has 
occurred rather suddenly. 

In cases in which death has been produced by drowning, the lungs 
contain very little water; but considerable maybe found in the stomach. 
If then a dead body be found in the water, and on examination, the 
stomach is found to contain water, the person probably perished by 
drowning. But, if on examination, the stomach contains no water, it is 
nearly certain that the dead body was thrown into the water. 

Treatment. — When a body is taken out of the water, and there re- 
mains a possibility of resuscitation, it should be wiped dry, wrapt in 
blankets, and taken to the nearest place suitable for making the necessary 
applications. 

The restoration of the action of the lungs, is the principle object to be 
aimed at, at the same time that warmth is communicated to the body, by 
warm flannels or otherwise. 

Artificial respiration may be produced, by passing the point of a 
common bellows into one nostril, and forcing the air gently into the lungs, 
the other nostril and mouth being closed, and the larynx pressed back by 
an assistant. When the air has thus gently been forced into the lungs, 
it should be allowed to escape through the mouth and nostril, its expul- 
sion being favored by pressure on the thorax and abdomen, and this 
process should be repeated ; imitating as near as possible, natural respi- 
ration, while a hope of resuscitation remains. 

In case, however, a bellows is not at hand, the mouth of the operator 
may be applied to the mouth or nose of the patient, the other being 
closed; and by taking full inspirations, the lungs of the patient may be 
filled, and the air then allowed to escape, being assisted by pressure on 
the thorax and abdomen. And this may be repeated, so as to imitate as 
near as may be, natural respiration. 

In case, however, one or both of these methods of producing artificial 
respiration, should fail, in consequence of the position of the tongue and 
epiglottis, closing the glottis ; the patient may be turned on the face, as 
suggested by Dr. Hall, so as to let the tongue and epiglottis fall forward. 
This being done, the patient must be turned gently upon one side; which 
position causes air to enter the lungs. Very soon the patient should be 
turned again gently upon the face, which position, with gentle pressure 



474 DISEASES OF THE RESPIRATORY SYSTEM. 

upon the back, expels the air, and again brings the tongue and epiglottis 
forward as before. This process may be repeated deliberately " every 
four seconds," or so as to imitate, as nearly as may be, natural respira- 
tion, and should be continued, while there is a remaining hope of return- 
ing vitality. 

While the effort to carry on artificial respiration is being made ; heat 
should be gradually communicated to the body, by warm flannels. 
Warmth should, however, be communicated gradually, for the sudden ap- 
plication of a high degree of heat might do injury, by destroying the 
the small degree of remaining excitability of the system. 

A strong infusion of capsicum in vinegar, is a very convenient appli- 
cation for the spine. Applied a little warm, with a flannel cloth, it tends 
to excite the circulation, and to impart warmth to the body. Injections 
of warm brandy and water into the rectum, may also be used, after the 
appearance of returning life begins to be manifested. 

The return of vitality is usually manifested by transient twitches of 
the muscles of the face, especially of those about the lips, succeeded by 
irregular and convulsive efforts at breathing, tremor and agitation of the 
extremities, a small weak pulse, breathing at long intervals, and a dis- 
charge of frothy fluid from the mouth. Sensation and the power of 
motion return gradually, the lips assume a red appearance, the skin 
becomes soft and warm, and in some instances vomiting takes place. 

When recovery has been partially affected, the greatest care should 
be taken that a due amount of stimulus be administered, to keep up 
the tottering energies of the system, at the same time avoiding over- 
stimulation. 

Such I believe are the most prudent and reliable measures for resusci- 
tation from apncea, produced by drowning or submersion. And a resort 
to them, modified of course to suit each particular case, should never be 
neglected, while there is a ray of hope of remaining vitality. 

APNCEA FROM STRANGULATION. 

By apnoea from strangulation, I mean that which is produced by a 
cord or other ligature about the neck, either with or without suspension. 

In either case death is caused by the exclusion of air from the lungs, 
produced by closure of the trachea. There is, however, great congestion 
of the cerebral veins, and in cases in which there is imperfect closure of 
the trachea there may be apoplectic effusion before death takes place. 
In cases, however, in which strangulation is produced by suspension 
there is sometimes a dislocation of the vertebrae, and death occurs in- 
stantly, from injury of the spinal cord " above the origin of the phrenic 
nerve." 

In the ordinary mode of executing criminals, then, if the vertebrae of 
the neck are dislocated, death occurs suddenly, with little or no suffering. 
In cases, however, in which there is no dislocation, but a perfect closure 
of the larynx, there is only a "brief feeling of suffocation," and con- 
sciousness becomes extinct. Finally, in cases in which there is no dis- 
location, and the closure of the trachea is incomplete, the suffering and 
consciousness continue for a longer period, and death ultimately occurs, 
in part from the exclusion of air, and also from cephalic congestion. 



APNOEA. 475 

In cases of apnoea from strangulation, if there is no dislocation of the 
vertebrae of the neck, even suspension may have been endured for a con- 
siderable time, and yet there may be the remains of vitality, which pro- 
per efforts at resuscitation may revive. 

Jlorbid Appearances. — The post-mortem reveals a congested state of 
the pulmonary arteries, right cavities of the heart, of the brain, and of 
the larger venous trunks generally, as in the bodies of persons drowned. 
There is also in addition the marks of the cord about the neck, and the 
dislocation of the vertebrae, in cases in which that occurs. The blood is 
imperfectly coagulated, if at all, and very little is found in the arteries, 
or left cavities of the heart. 

Treatment. — The treatment consists in producing artificial respiration, 
imparting warmth, affording stimulus, and should be in nearly every par- 
ticular the same as in cases from drowning, only from the manner in 
which the cause acts, the cerebral congestion may require the abstrac- 
tion of blood from the jugular veins. Or blood may be taken from the 
back of the neck by cups, with very good effects. In a case of hanging 
(an attempt at suicide) which came under my care, in this village, about 
three years since, resuscitation was quite complete ; but the patient could 
not swallow till I took a few ounces of blood, by cups, from the back 
of the neck. The case subsequently passed on favorably, and finally 
recovered. 

APNOEA FROM IRRESPIRABLE GASES. 

Of the various irrespirable gases capable of producing apnoea, carbonic 
acid is by far the most frequent. When a person in health is exposed 
by accident or otherwise to carbonic acid in its pure state, apnoea and 
finally death occurs, probably from the absence of oxygen and also in 
part perhaps by the obstruction which the gas affords to the free exhala- 
tion of carbonic acid from the lungs. When apnoea or death is thus 
suddenly produced, the body is found pale, collapsed and flaccid. 

If, however, as is often the case, the carbonic acid is mixed with atmos- 
pheric air, it produces vertigo, fainting, insensibility, apnoea, and if con- 
tinued, finally death. In such cases the face exhibits a tumid and livid 
appearance, the veins of the head and neck are turgid, the tongue is 
swelled, and the lips livid; and the body may remain warm for several 
hours. 

The inhalation of chloroform may produce apnoea, in part perhaps by 
" depressing the nervous centre of respiration," and also by excluding 
atmospheric air from the lungs. 

Nitrogen and hydrogen gases are seldom accidentally inhaled, and 
when they are, produce apnoea or death, not by any positive pernicious 
effect, but by their utter incapacity to sustain animal life. The other, 
and highly irritating gases, such as the muriatic acid gas, chlorine, &c, 
seldom enter the lungs in quantity sufficient to produce apnoea; they 
may, however, inflame the respiratory passages and thus lead to a fatal 
result. 

Morbid appearances. — The appearances on dissection are similar to 
those exhibited from drowning; the sinuses of the brain, the jugulars, 
and all the large venous trunks as well as the right cavities of the heart 



476 DISEASES OF THE RESPIRATORY SYSTEM. 

and pulmonary arteries, are always congested with dark blood, and gene- 
rally in a fluid state. The pulmonary veins, left cavities of the heart, 
and arteries generally, are nearly empty, as in cases of drowning and 
strangulation, and for a similar reason. 

Treatment. — In cases of apnoea from carbonic acid, in which there is 
some degree of sensibility remaining, the patient should be taken imme- 
diately into the open air, and being supported in the sitting posture, cold 
water should be dashed upon the face and breast, while the extremities 
are rubbed with warm flannel ; and as soon as the patient is able to swal- 
low, a little cold wine or brandy and water may be administered. 

In cases, however, of apnoea from carbonic acid, in which there is no 
apparent remaining sensibility, the patient should be taken into fresh 
cool air, and being stript and laid on a sheet, with the head and shoulders 
elevated, cold water should be dashed upon the breast, and cloths wet in 
cold water applied to the head. 

The cold affusions may be repeated at short intervals, and spirits of 
ammonia or camphor applied to the mucous membrane of the nose. The 
back and extremities may be rubbed with a strong infusion of capsicum 
in vinegar, and an injection of carbonate of ammonia or warm brandy in 
mucilage may be administered with very good effect. In case the cold 
affusions fail to excite respiration, artificial respiration should be resorted 
to as for drowning; and as soon as resuscitation is established, the 
patient should be wiped dry and a little warm wine-whey may be allowed. 

The same treatment may be resorted to, in cases of apnoea from the 
other unirritating gases, such as hydrogen, nitrogen, &c, and also for 
the apnoea, should it occur from the irritating gases. But accidents 
from hydrogen or nitrogen gases seldom occur. And when the irritating 
gases are accidentally inhaled, the principal danger, as we have seen, is 
from the inflammation which they produce in the respiratory passages, 
which, of course, requires to be treated on general principles, laid down 
elsewhere. 

Such, I believe, are the principles which should guide in the treatment 
of apnoea from the irrespirable gases; subject of course, to variations, 
to suit each particular case. 

APNCEA FROM ELECTRICITY. 

Moderate currents of electricity passed through the human body, ap- 
pear to produce an invigorating effect. But when its intensity is great, 
it impairs or suspends the sensibility of the nervous system, and pro- 
duces apnoea, insensibility, or utter loss of vitality, if the shock be very 
great. 

The appearance of persons struck by lightning, vary therefore, ac- 
cording to the intensity of the shock. If the shock has been severe, 
there is no appearance of sensibility remaining. Red streaks may be 
found on different parts of the body, the hair may be found singed, small 
blisters appear on different parts of the body, and blood may be discharged 
from the ears. 

When the electric stroke has been less intense ; so as not to destroy 
sensibility, the face appears red and bloated, blood issues from the mouth 
and nose, respiration is difficult, the pulse is weak and irregular, and not 



' APNCEA. 477 

unfrequently, there are spasmodic twitches of the muscles of the face, 
throat, and other parts of the body. 

Persons recovered from a state of apncea from lightning, are apt to 
suffer for a long time, from painful sensations, and a degree of numbness 
in the extremities; and they frequently retain a peculiar susceptibility 
to the electric influence for a long time. 

Morbid Appearances. — The post-mortem in persons killed by lightning 
reveals a collapsed state of the lungs ; but the heart is apt to be gorged 
with blood. In cases in which death has been sudden, the blood is found 
in a fluid state, and the body tends rapidly to putrefactive decomposition. 

Treatment. — The treatment for apnoea from lightning, should be simi- 
lar to that for apnoea, arising from carconic acid, and the other gases. 
The patient should be placed in a convenient position, and cold water 
should be frequently, and copiously dashed over the whole body. Friction 
should also be made with rough flannel, and should the cold affusion fail 
to excite respiration ; artificial respiration should be resorted to, and the 
effort persevered in, while there is any hope of returning sensibility. 

In desperate cases, in which the ordinary efforts at resuscitation are 
ineffectual; galvanism or electricity, if at hand, may be resorted to; but 
generally, I think, with little prospect of success. It should be applied 
in moderate currents, and so, if possible, as to excite the respiratory 
movement. 

Discretion should be exercised in adopting the measures used to the 
condition of each particular case. And should sensibility return, a little 
wine-whey may be required ; but care should be taken to avoid over- 
stimulation. 

APNCEA FROM COLD. 

When the human system is exposed to intense cold, the suffering is at 
first very considerable, in consequence of the impression on the extreme 
nerves. If, however, the exposure continues till reaction ceases, it pro- 
duces a benumbing effect, and there is evinced, soon, signs of cerebral 
oppression. The surface becomes pale and contracted, the superficial 
blood-vessels shrink, the extremities become numb, the gait is tottering, 
the voice indistinct, and, if the exposure continues, there is an irresist- 
ible drowsiness ; and finally, apnoea, insensibility, and death is the 
result. 

Morbid Appearances. — The post-mortem reveals a gorged state of the 
large venous trunks, and though the arteries are generally comparatively 
empty, both sides of the heart are in some cases filled with blood, im- 
perfectly coagulated. Most of the large viscera, as well as the brain, 
are gorged with blood, but there is generally no apoplectic effusion,. 

Treatment. — Resuscitation from apnoea, caused by intense cold, may 
sometimes be effected after all the sensible phenomena of life have be- 
come extinct. 

When a person is found in a state of insensibility from cold, the body 
should be rubbed with melting snow, if at hand, and as soon as convenient 
it should be immersed in spring water, or water fresh from the well. 
After twenty or thirty minutes the body should be taken from the cold 



478 DISEASES OF THE RESPIRATORY SYSTEM. 

water, and rubbed dry with soft flannel, after ■which it should be wrapt 
in blankets, and taken "into an unheated room." 

The body should now be rubbed with flannel, and if respiration does 
not return, artificial respiration should be resorted to. And these mea- 
sures should be persevered in till all hope vanishes, or there is a return 
of sensibility. If the measures are successful, the temperature of the 
room should be gradually raised, and when the power of deglutition is 
restored, warm sage tea and a little wine-whey may be allowed, till reac- 
tion is fully established. 

SECTION XV.— PNEUMOTHORAX. 

Ey pneumothorax is here meant, air in the cavity of the pleura, either 
with or without a fluid. 

Pneumothorax may arise from an accumulation of gas in the cavity 
of the pleura, without any direct communication with the external air, 
or it may occur from a communication of air through the bronchial 
tubes, or finally, by a direct communication of air through the walls of 
the chest. 

Symptoms. — The accumulation of air in the cavity of the pleura pro- 
duces compression of the lung, and, as a consequence, is attended almost 
invariably with more or less dyspnoea. 

If the accumulation is small and the pleura contains little or no fluid, 
the respiratory organs as well as the circulation may accommodate 
themselves gradually to the morbid condition, and the dyspnoea and other 
symptoms may be comparatively slight. 

In cases, however, in which the accumulation is sudden and consider- 
able, there is great difficulty of breathing, a sharp pain in the side, and 
sometimes a copious expectoration of pus, as happened in one case that 
fell under my observation, the result of empyema. 

In cases in which there is considerable fluid in the cavity of the pleura, 
and the air enters from the bronchial tube or tubes below its surface, 
little or no air is expelled at each expiration, and thus the accumulation 
may become very great and lead even to fatal suffocation. Or, in case 
one lung has been incapacitated, from any cause, for respiration, and 
pneumothorax occurs in the opposite side, fatal suffocation generally 
speedily occurs. 

Diagnosis. — Inspection may detect an enlargement of the side or 
bulging of the intercostal muscles. Percussion on the affected side elicits 
a dull sound as high in the chest as the liquid extends, if there is any, 
but above there is a clear or tympanitic sound, very different from that 
elicited on the opposite side of the chest. 

If the ear be applied to the affected side there is noticed a want of the 
respiratory murmur and a diminution of the vocal resonance, both of 
which may be rendered more apparent by comparing them with the 
sounds on corresponding parts of the opposite side. In some cases of 
pneumothorax, however, there is detected on the affected side the am- 
phoric respiration as well as the amphoric resonance of the voice and 
cough, and also the metallic tinkling. These last symptoms are not, how- 
ever, strictly diagnostic, as they occur in large cavities in the lung as 
well as in pneumothorax. 



EMPHYSEMA. 479 

In cases of pneumothorax in which there is considerable liquid in the 
cavity of the pleura, with the air, succussion produces a "splashing" 
sound, which may be distinctly heard on applying the ear to the chest; 
and the patient may feel a peculiar sensation on coughing, caused by the 
striking of the fluid against the costal pleura. 

Causes. — Pneumothorax may arise from the opening of a tuberculous 
vomica into the cavity of the pleura, there having been previously a 
communication with the bronchial tubes, or it may arise in cases of 
empyema from an ulceration in the pleura and pulmonary tissue into the 
bronchial tubes, as happened in one case that fell under my observation ; 
the matter from the pleural cavity in this case being gradually expecto- 
rated. In this case the external application of iodine ointment caused a 
suspension of the accumulation of matter in the pleural cavity for a time, 
so that the passage to the bronchial tubes healed. Subsequently, how- 
ever, matter again accumulated, and pointing in the intercostal space, in 
a convenient place, I opened it and got at first about a gallon of sero- 
purulent matter, from the escape of which the patient suffered very little. 
The patient, a young man, lived for several years with pneumothorax, 
from the puncture in the walls of the chest, and finally died of anasarca. 

Finally, pneumothorax may arise from the gases extricated in gan- 
grenous decomposition of the lung or lungs, and it may also arise from 
an accumulation of gas in the cavity of the pleura, probably without any 
organic lesion, and from various other causes which I need not mention. 

Treatment. — The general condition of fe the patient should be corrected 
as far as possible by proper remedies: local inflammations should be over- 
come by cups, leeches, blisters, &c. ; iodine externally and internally 
may be required to remove the liquid effusion, if it exists, and in cases 
in which the accumulation of air in the cavity of the pleura threatens 
suffocation, an opening may be made in the walls of the chest for its 
escape. 

In cases in which the cause of the pneumothorax is of a necessarily 
fatal character, palliatives only may be required, and an opening in the 
walls of the chest for the escape of air, may not be advisable even though 
suffocation be threatened. 

But in cases in which the cause is not of a necessarily fatal character, 
the iodide of potassium and some preparation of iron, or the syrup of the 
iodide of iron may be indicated and should be continued for a long time. 
This course of treatment, with counter irritants, and finally iodine oint- 
ment externally, with puncture of the walls of the chest, if necessary, 
may lead to a final recovery. 

SECTION XVI.— EMPHYSEMA. 

By emphysema, I mean here that which arises from an enlargement 
or dilatation of the air-cells, and also the escape of air from a laceration 
of the larynx, trachea or lungs, producing interlobular infiltration of air, 
and extending, in some cases, into the general cellular tissue, distending 
the mediastinum, face, neck, and superior part of the chest. 

Symptoms. — Vesicular Emphysema, or that which arises from exces- 
sive dilatation of the air-cells, is attended with dyspnoea, which may be 



480 DISEASES OF THE RESPIRATORY SYSTEM. 

continuous, but is greatly increased by over exercise, or any cause "which 
calls for an increased action of the lungs. 

During a paroxysm, from whatever cause produced, the face is apt to 
be pale or livid, the lips purple, and in protracted cases, the counten- 
ance may assume a continuous "dusky hue." 

In the interlobular or extravehicular variety, one marked case of which 
fell under my observation, in this village, a few years since, the air is 
liable to escape into the general cellular tissue, especially if the air 
escapes from the larynx, trachea, or near the root of the lung, or lungs. 
In such cases, the air distends the mediastinum and adjoining cellular 
tissue, and frequently, also, the face, neck, and superior part of the 
chest, as happened in the case above referred to, in this village, which 
affected both sides, and produced fatal suffocation or dyspnoea. 

On inspection, the affected side is found more convex or prominent 
than in health, and the intercostal spaces appear slightly widened. Per- 
cussion elicits an increased resonance, in proportion to the amount of air 
the lungs contain. 

Auscultation detects a feeble and suppressed, or short inspiration, and 
a loud, protracted and wheezing expiration, and this is true, I believe, 
whether the emphysema be vesicular, or extra vesicular or interlobular. 

Anatomical Characters. — On opening the chest, in cases of vesicular 
emphysema, the lung does not collapse, but rather expands. The lung 
sinks less in water than in a natural state, and its surface is often 
covered with slight elevations, consisting of dilated air-cells. 

On cutting into the lungs, the air-cells of more or less of one or both 
lungs are found dilated, some slightly, others to the size of a " hazel- 
nut," or even larger than that, and there is generally more or less dila- 
tation of the small bronchial tubes in the affected part. 

In interlobular or extravesicular emphysema, elevations may be found 
on the surface of the lungs, from the size of a pea to that of a hen's 
egg, or even larger, caused by the rupture of air-cells, and escape of air 
into the pulmonary structure. The interlobular cellular tissue, through- 
out the affected part is filled with effused air, in such cases, as might be 
expected. 

In cases of extravesicular emphysema in which the air escapes into 
the mediastinum and surrounding cellular tissue, and also into the gene- 
ral cellular tissue, distending the neck, face, and upper part of the chest, 
the lungs may be compressed, and fatal suffocation or dyspnoea produced, 
if both sides of the chest are involved. 

In a case of this character that I examined, already referred to, 
in which the air escaped near the root of the lungs, the rupture having 
been produced by straining at stool, the following appearances were pre- 
sented on examination post-mortem. 

There was a general bloated or distended appearance of the face, 
neck, and superior part of the chest of both sides. On removing the 
sternum, the anterior portion of the chest was found filled with distended 
cellular tissue, containing some adipose matter, appearing to fill most of 
the space usually occupied by the anterior and inferior portion of the 
lungs. The lungs were found in the posterior part of the chest, in a 
sort of collapsed or very contracted state, and almost black from the 



AUSCULTATION OF THE HEART. 481 

little venous blood which they contained. In this case the emphysema 
was of both sides ; and I ascertained from his attendants that death 
took place very soon after the occurrence of the emphysema. 

Causes. — Vesicular emphysema is most frequently produced by 
asthma, bronchitis, and pulmonary phthisis, but it may be produced by 
any cause which interrupts the free expiration of air from the lungs. 
The extravesicular variety of emphysema may be produced by any cause 
which keeps the lungs too long in an expanded state. 

It is probable that the most frequent causes of this variety of the dis- 
ease, are lifting heavy weights, blowing on wind instruments, straining 
at stool, and protracted holding in the breath, as in diving, &c. 

Treatment. — The cause should be sought out and removed, as far as 
possible, and the patient should be made to conform strictly to the laws 
of health in every respect. 

In the chronic vesicular variety, violent exercise, and every other 
cause capable of bringing on a paroxysm of dyspnoea should be carefully 
avoided. But should a paroxysm occur, small doses of hive-syrup, tincture 
of lobelia and stramonium may be of service. Half a drachm each of hive- 
syrup and tincture of lobelia, with ten drops of the tincture of stramo- 
nium, may be administered every six hours till the paroxysm subsides. 

In the extravesicular variety, if threatening, general bleeding may be 
required, to lessen the pulmonary circulation, and if the face, neck or 
chest become distended with air, punctures may be made for its escape. 



CHAPTER X. 

DISEASES OF THE CIRCULATORY SYSTEM. 



SECTION I.— AUSCULTATION OF THE HEART. 

Before proceeding to the consideration of diseases of the circulatory 
system, including those of the heart, arteries, veins, capillaries, lympha- 
tics, and lacteals, as well as deranged or diseased conditions of the cir- 
culatory fluids, which I propose to do in the present chapter, I shall in 
this section attempt to explain the natural and diseased sounds of the 
heart and large arteries, discoverable by auscultation, percussion, &c. 

But before we proceed to the consideration of auscultation of the 
heart, it is necessary to take a general glance at the circulatory system, 
and to call to mind, definitely, the anatomy and physiology of the heart, 
leaving the minute anatomy and physiology of other parts of the circu- 
latory system to be called up as we proceed to the consideration of dis- 
eases affecting these different parts. 
31 



482 DISEASES OF THE CIRCULATORY SYSTEM. 

The heart, it will be remembered, is the central organ of the circula- 
tory system, and is situated between the two layers of pleura, which 
constitute the mediastinum, being enclosed in the pericardium. 

The heart is placed obliquely in the chest, the base being directed 
upwards and backwards, or towards the right shoulder, " and the apex 
forwards, and to the left, pointing to the space between the fifth and 
sixth ribs," two or three inches to the left of the sternum. The heart 
is a muscle, and has four cavities ; the right auricle and ventricle occupy- 
ing its right side, and the left auricle and ventricle the left. 

The right auricle receives the venous blood from all parts of the sys- 
tem, as well as the lymph, chyle, &c, and passes it on through the 
auriculo-ventricular opening into the right ventricle. From the right 
ventricle, by its contraction and the closing of the tricuspid valve, the 
blood is passed on through the pulmonary artery to the capillaries of the 
lungs, where, parting with carbonic acid and receiving oxygen, it is pre- 
pared to pass on, as arterial blood, through the pulmonary veins to the 
left auricle. From the left auricle the blood passes through the auriculo- 
ventricular opening into the left ventricle, from which, by contraction of 
its walls, and closure of the mitral valve, it is forced on into the aorta, 
by the contraction of which, together with the closure of the semilunar 
valves, it is distributed to every part of the system. 

The arterial blood in passing through the minute capillaries, consti- 
tuting the connection between the extreme arteries and veins, supplies 
materials of growth or nutrition, and gradually assuming a darkish color 
passes on through the veins to the right auricle of the heart, from whence 
it started. 

But some albumen probably escapes from the small blood-vessels, and 
more is set free " by changes going on in the soft parts," in the breaking- 
down of the old tissues. Now to take up this extravasated and other albu- 
minous matter everywhere in the system, and to change or turn it, as 
far as may be, to fibrin, the lymphatic system is arranged, consisting of 
" a network of delicate tubes" " disseminated through all the soft tissues 
except the nervous." These tubes coalesce, producing those of larger 
size, and pass through the lymphatic glands "which," says Professor 
Draper, "might indeed be regarded as mere plexuses, and eventually 
empty into the veins."* 

The lacteal vessels constitute the remainder of the vascular system, 
and consist of small vessels, which arise along the intestines in the sub- 
mucous tissue, and passing through the mesenteric glands, terminate in 
the thoracic duct. The mesenteric glands, through which the lacteals 
pass, consist, according to Professor Draper, of a " plexus of tubes, to 
which that particular form is given for the sake of closeness of pack- 
age,"f and it is probable that they change a portion of the fat and albu- 
men of the chyle, as well as that transuded from the blood-vessels, along 
the intestines, to fibrin, thus rendering their functions very similar to 
that of the lymphatic glands in other parts of the system. 

The thoracic duct commences in the receptaculum chyli, which is made 
up of several lymphatic trunks, together with the lacteals, and is situated 
in front of the second lumbar vertebra. The duct, thus originating passes 

* See Draper's Physiology, pp. 94, 95. f See Draper's Physiology, p. 89. 



AUSCULTATION OP THE HEART. 483 

up in front of the vertebral column to the fourth dorsal vertebra. It then 
inclines to the left, ascends by the side of the oesophagus to opposite the 
seventh cervical vertebra. At this point it " makes a curve forwards and 
downward, and terminates at the junction of the left subclavian, with the 
left internal juglar vein." Through the lacteals and thoracic duct the 
fat and albumen of the chyle, derived from the food, and also the albumen 
derived by transudation from the systemic blood, being in part turned to 
fibrin in the mesenteric glands, reaches the general circulation. 

Thus have we taken a glance at the circulatory system, including the 
heart, arteries, veins, lymphatics, and lacteals, every part of which will 
constantly be called up, as well as the character of the blood, chyle, 
lymph, &c, as we proceed in the consideration of diseases of the circula- 
tory system. 

With these preliminary considerations, and bearing in mind the minute 
anatomy of the heart, let us proceed to the consideration of the topic of 
the present section, auscultation of the heart. 

We have seen how the blood passes through the heart, and we 
should naturally suppose that the contraction of its cavities and closure 
of its valves, together with the passage of the current of blood, would 
produce a sound or sounds, and an impulse, and such is really the case. 

Now in order to appreciate the morbid sounds, impulse of the heart, &c, 
it is necessary to inquire into the physical signs which occur in health, 
including the impulse, rhythm, and sounds of the heart, and then we may 
fully appreciate the morbid. 

Impulse. — If the hand be placed on the left side of the chest, below 
the nipple, in the space between the fifth and sixth ribs, a little to the 
inner side of a line running vertically over the nipple, a gentle regular 
pulsation is felt, and if the ear or stethoscope is applied to the same part, 
a slight shock is perceived by the examiner. "This is the impulse of the 
heart," and depends upon the impinging of its apex against the parietes 
of the chest, being nearly synchronous with the pulse at the wrist, and 
with the systole or contraction of the ventricles. 

Rhythm. — If the ear be placed upon the praecordial region, when the 
heart is acting naturally, a regular succession and cessation of sounds is 
heard. In the first place there is noticed a long sound, then a short 
sound, and then an interval without any sound, after which will occur 
again the long, then the short sound, and then the interval as before. 

The long and short sound, together with the interval, make up the 
time occupied by one complete circuit of the heart's functions. And as 
these sounds and this interval have been observed constantly to bear a 
definite relation to each other, the period occupied by them, or the com- 
plete circuit of the heart's action has been divided into corresponding por- 
tions of time. 

" Suppose then," says Dr. Hughes, " that the whole period of this 
time be divided into fifths, the first sound will occup}?- two fifths, the 
second sound one-fifth, and the interval between the sounds, the remain- 
ing two-fifths. The time occupied by the whole corresponds to the time 
between one stroke of the pulse and another, so that if a person's pulse 
beat eighty times in a minute, there would be eighty long sounds, eighty 
short sounds, and eighty intervals." 



484 DISEASES OP THE CTRCULATOKY SYSTEM. 

Sounds. — The sounds of the heart, as suggested by Dr. Hughes, may 
be represented by the following syllables; too-to, too-to. 

The first sound of the heart is caused, as I believe, by the contraction 
of the ventricles and reaction, or tendency to flow back of the blood, and 
closure of the tricuspid and mitral valves ; the shock thus produced being 
communicated to the parietes of the chest. This may be understood, 
when we remember that the contraction of the ventricles occurs at the 
same time that the auricles are relaxed or dilated, the blood being sud- 
denly arrested by the tricuspid and mitral valves, producing the shock 
and sound referred to. 

The second sound of the heart is caused probably by the sudden reaction 
of the blood on the semilunar valves, after it has passed out of the ven- 
tricles. This may be understood, when we remember that the diastole of 
the ventricles, takes off the pressure from behind, and allows the blood 
to react suddenly on the semilunar valves ; producing vibrations of the 
vessels, and consequently of the parietes of the chest, and hence the 
second sound of the heart. 

The ordinary range of the heart's sound, when in a natural condition, 
and free from disease, is over the precordial region, where they may be 
distinctly heard, by the application of the ear or stethoscope. 

Impulse in Disease. — As a general rule, the impulse of the heart in 
disease, is as the pulse at the wrist. If the pulse is strong and vigorous, 
the impulse of the heart is so likewise; but if the pulse is feeble and de- 
pressed, so is the impulse of the heart, and when the pulse is contracted 
and vibrating, the impulse of the heart partakes of the same character. 

When hypertrophy exists, the parietes of the auricles, and ventricles 
being thickened, the impulse is powerful and heaving. And when, with 
the thickening, dilatation also exists, the impulse is powerful, and more 
diffused; being often felt over the whole precordial region. 

When the parietes of the ventricles are thin and weak, or loaded with 
fat, the impulse is feeble. But when with this weakness, the cavities of 
the ventricles are dilated, though the impulse is weak, it will be felt over 
a larger extent of surface than in a healthy state. 

When the patient examined is nervous or anaemic the impulse is ex- 
ceedingly sharp and smart, but care should be exercised not to confound 
this with a strong impulse. 

When obstruction exists in the pulmonary artery or in the mitral 
valve the impulse is increased, in the scrobiculus cordis, in consequence 
of the continued distension of the right ventricle, which results from 
such obstruction. 

When the mitral valve becomes insufficient, allowing regurgitation of 
the blood for a long time, the whole heart, with the exception of the 
left ventricle, becomes dilated and enlarged. In such cases, in addition 
to the increased impulse at the scrobiculus cordis, there is an impulse 
between the cartilages of the third and fourth ribs, which probably arises 
from regurgitation through the mitral valve, if it be synchronous with 
the impulse at the scrobiculous cordis ; but if not, it may arise from an 
increased action of the auricle itself, caused by the regurgitation. 

In cases in which there is an obstruction in the aortic valves, or in the 
arch of the aorta, the overaction of the left ventricle may increase its 



AUSCULTATION OF THE HEART. 485 

strength, and also the impulse of the heart. If, however, in such cases 
the patient is thin and weak, the ventricle may become dilated and thin, 
and the impulse, though extended, becomes very weak. 

If fluid be effused into the pericardium, in small quantity, the impulse 
of the heart is only decreased ; but if the fluid be in large quantity, the 
impulse may be lost, or its position materially changed.. 

The Rhythm in Disease. — Any impression which excites the action of 
the heart, may at the same time disturb its rhythm. In such cases, one 
cavity contracts before its time, or another is dilated too quickly, in con- 
sequence of which the natural series of actions is interrupted, and the 
regular succession broken. Hence it is, that organic changes of the 
heart, which interfere most with the circulation through the organ, most 
frequently produce an unnatural rhythm. 

Among the causes which thus interfere with the circulation through 
the heart, and produce an unnatural rhythm, are diseases of the valves, 
especially of the mitral valve, thinness and dilatation of the parietes of 
the ventricles, and effusion into the pericardium. All these causes, with 
many others, may operate to produce different varieties of unnatural 
rhythm, from the treble beat to an utter confusion of sounds, or in the 
succession of sounds. 

Sounds in Disease. — The sound of the heart may be unnaturally in- 
creased or decreased, or concealed by morbid sounds or murmurs. 

Increased Sounds. — In cases in which the valves are healthy, and the 
cavities of the heart dilated, the parietes of the ventricles being thinner 
than natural, there is generally an increase in the heart sounds. 

Decreased Sounds. — Anything which interferes with the free action of 
the heart, or impedes the motion of its valves and regular contraction of 
the organ, may produce a diminution of the natural sounds of the heart. 
The most frequent causes probably of decreased sounds, are fluid in the 
pericardium, distention of the heart, and imperfection of the valves. 

Murmurs. — In a perfect state of health, the heart and blood being 
natural, no noise is produced by the direct transmission of the blood 
through the heart, " in a quiet stream." In case, however, the valves be- 
come thickened by inflammation, as in endocarditis, they lose their 
pliancy and flexibility, and do not set close to the walls of the vessels, 
or leave a free passage for the blood, in consequence of which an un- 
usual agitation is produced among the particles of the blood, which gives 
rise to morbid sounds or murmurs. 

The morbid sounds, or murmurs thus produced are various. It may 
resemble the sound produced by a pair of bellows, in which case it is 
called the " bruit de souflet" or " bellows murmur" or it may resemble 
the rasping of "wood, constituting the " bruit de rape" or the " rasping 
murmur" or the sound may be like that produced by the sawing of 
wood, constituting the " bruit de scie" or " sawing murmur" or finally 
the sound may resemble the tone of musical instruments, constituting the 
" bruit" or " musical sound." 

Such I believe are the principal murmurs, liable of course to varia- 
tions, and to more or less commingling, which modifications are always 
to be taken into account in the examination of cases. 

But in order to understand in what valve or valves the morbid condi- 



486 DISEASES OF THE CIRCULATORY SYSTEM. 

tion producing the murmur exists, it is proper for us to inquire more 
particularly in relation to the seat or location in the chest, of the differ- 
ent valves, or the points at which the murmurs proceeding from them may 
be most distinctly heard. 

The valves of the pulmonary artery are situated nearly opposite the 
cartilage of the third rib, on the left side of the sternum, at which point 
murmurs proceeding from that source may be most distinctly heard. 

The aortic valves are situated deeper, and their murmurs heard most 
distinctly over the sternum, nearly opposite the cartilage of the third 
rib, or a little below. 

The mitral valve is situated nearly opposite the space between the 
cartilages of the fourth and fifth ribs, a little to the left of the sternum 
and below the nipple. 

The tricuspid valve is situated immediately behind the lower part of 
the sternum, and murmurs arising from disease of this valve, are heard 
most distinctly over the central part of the sternum, but are sometimes 
audible at the scrobiculus cordis. 

Regurgitation. — We have seen that murmurs are produced by the di- 
rect passage of blood through imperfect valves, it must be remembered 
also that murmurs may arise from a regurgitation, or retrograde motion 
of the blood through diseased valves. 

"When regurgitation takes place through the aortic valves," the di- 
rect current not being interrupted, a murmur is heard over the sternum, 
a little below the third rib. This murmur occupies the time of, and may 
conceal the second sound of the heart. But if the pulmonary valves are 
in a perfect state, the murmur and the second sound may be heard toge- 
ther, between the cartilages of the second and third ribs, a little to the 
left of the sternum. 

If, however, "both obstructions exist in, and regurgitation takes 
place through the aortic valves, a double murmur or see-saw sound 
is heard over the sternum, opposite the third rib." This sound may be 
heard along the course of the aorta, but gradually diminishes as the ear 
is passed from over the seat of the aortic valves. Should obstruction 
exist in, and regurgitation take place through the pulmonary valves, this 
see-saw sound, or double murmur will be heard nearly opposite the cartil- 
age of the third rib to the left of the sternum. 

In case regurgitation takes place through the mitral valve, the mur- 
mur occupies the time of the first sound of the heart and is most distinctly 
heard between the cartilages of the fourth and fifth ribs, a little to the 
left of the sternum and below the nipple. It may also be audible in the 
axilla, close by the spine, in the interscapular region, or even "over the 
bony column itself." 

Aneurism of the ascending or descending aorta, or of other large 
arteries, may give rise to murmurs similar to those produced by the 
direct or retrograde movement of the blood through diseased valves, and 
hence they afford an important diagnostic symptom in aneurism of the 
aorta and of other smaller arteries. 

Ansemic murmurs. — In certain anaemic conditions, as in chlorosis, 
murmurs may arise from the mere passage of the blood independently 
of local disease; they are very properly called " anwmic murmurs," and 



AUSCULTATION OF THE HEART. 487 

may resemble the blowing of a pair of bellows; "the bruit de souflet ;" 
or the sound may be rough like that of filing or sawing, "the bruit de 
rape,'' or "bruit de scie." 

These anaemic murmurs appear to be connected either with the aortic 
openings or with the pulmonary artery, and depend, probably, upon a 
dissolved or watery state of the blood; in consequence of which, its 
particles move easily over each other, are therefore more freely agitated, 
and thus give rise to the vibrations which produce the murmurs. 

Venous murmurs. — In anaemic patients there may sometimes be heard 
a murmur by the passage of blood along the jugular veins ; this murmur 
is continuous and not intermittent like the arterial murmurs, and has 
been called the "continuous humming" or " venous murmur." 

Strong pressure causes it to cease, but it is seldom heard distinctly 
unless slight pressure be made over the part. It probably depends upon 
a watery state of the blood, upon its accelerated motion, and in part 
perhaps upon the slight obstruction produced by the gentle pressure 
made over the part. 

Pericardial murmurs. — The natural movements of the hear^ in the 
pericardium, in a state of health, are not attended with any audible 
sound ; but when the pericardium is rendered rough by inflammation, or 
when lymph is thrown out on its folds, attrition occurs, and a superficial 
rubbing is heard over the pericardial region upon each motion of the 
heart, called the "pericardial rubbing " or "frottemont." 

The murmurs, however, in such cases, vary according to the degree of 
roughness of the parts, being in some cases a mere "frottemont" or 
simple rubbing sound ; in others harsh, grating, or creaking, and in others 
still resembling the bellows murmur of the valves. 

Mixed murmurs. — It sometimes happens that the pleura, which is in 
contact with, or forms the external covering of the pericardium, becomes 
inflamed and roughened, and perhaps also, that portion of the pulmonary 
pleura, immediately adjoining, in which case there is a murmur produced 
by the attrition of the two roughened surfaces. This murmur may gener- 
ally be heard most distinctly, during inspiration, as the motion of the 
pericardial and pulmonary pleura is most considerable at that time. 

Finally, it occasionally happens, that a small amount of fluid collects 
in the immediate vicinity of the heart, with or without the presence of 
a gas, in such a position that each impulse of the heart produces in it a 
degree of agitation sufficient to cause an audible sound or murmur. 

This noise has been very correctly represented by Dr. Hughes, by the 
syllables "blob — blob — blob — blob." In one case that fell under my obser- 
vation, in this village, a few years since, this peculiar sound was audible 
for several weeks, and was often so loud, that it was distinctly heard in 
any part of the room, in which the patient — a young lady, was sitting 
or lying. 

Such, according to my observation, are the natural, and most common 
diseased sounds of the heart, detected by auscultation. But there are 
certain diseases of the heart and pericardiun, in which percussion elicits 
sounds indicative of morbid conditions within, which it is proper to notice 
as we pass. 



488 DISEASES OF THE CIRCULATORY SYSTEM. 

PERCUSSION. 

Enlargement of the heart, is attended with increased dullness on per- 
cussion, of the precordial region, and this increased dullness is most 
marked, over that portion of the heart in which the dilatation is most 
considerable. In case the left ventricle is greatly dilated, the dullness is 
most marked below the left nipple, over the costal cartilages. 

If it is the left auricle that is mainly dilated, the increased dullness will 
be most conspicuous on the third and fourth ribs, and their cartilages, to 
the left of the sternum. If, however, it is the right ventricle that is more 
especially involved in the dilatation, the increased dullness will be noticed 
most to the right of the sternum, at the inner edge of the right mam- 
mary region, and at the scrobiculus cordis. 

In pericardial effusion, if the quantity of fluid is considerable, there 
is dullness on percussion, and this dullness begins on the left side of the 
lower portion of the sternum, and gradually extends upwards. But when 
the pericardium is largely distended, the dullness is very remarkable, 
and extends in every direction ; but especially transversely and inferiorly. 

Aneurism of the ascending aorta, if of large size, may generally be 
recognized by dullness on percussion, in the upper sternal, and "inner 
edge of the right subclavian region." In case, however, the aneurism is 
very near the heart, percussion would hardly distinguish aneurism from 
disease of the heart itself. 

In case the aneurism occupies the arch of the aorta, there is generally 
marked dullness on percussion over the affected part. 

Finally, if aneurism exist in the descending aorta, and is of a large 
size, it may generally be detected by dullness on percussion on either, 
but especially on the left side of the spine. And in case it projects for- 
ward, dullness may be perceptible "in the precordial region." 

Such, I believe, are the abnormal sounds elicited on percussion, in en- 
largement of the heart, pericordial effusion, and aneurism of the large 
vessels, which completes what I had to say on auscultation of the heart. 

SECTION II.— PERICARDITIS. 

By pericarditis, from TtJptxrapScov, "the pericardium," and itis, inflam- 
mation ; I mean inflammation of the pericardium, whether of a simple 
serous or rheumatic character. 

The pericardium, it will be remembered, consists of two layers, " an 
external fibrous and internal serous." The fibrous layer is attached to 
the great vessels at the root of the heart, and is continuous with the tho- 
racic fascia. The serous membrane lines the inner surface of the fibrous 
layer, and is then reflected over the heart, which it covers entirely, 
"without, however, having the heart within it;" in this respect resem- 
bling other serous membranes. 

" The pericardium envelops the heart, retains it in position, and facili- 
tates its movements, by the serous fluid which it contains in greater or 
less quantity." 

The pericardium, thus constituted, is liable to become inflamed, and 
the character of the inflammation, as well as the symptoms developed, 
depend very much on the membrane principally involved. 



PERICARDITIS. 489 

If the inflammation be seated mainly in the serous membrane, it is 
generally acute, and marked by symptoms that usually attend inflamma- 
tion of serous membranes. In such cases, the inflammation is peculiarly 
liable to terminate in effusion of serum, producing hydropericardium. -. 

If, on the other hand, the inflammation is confined mainly to the 
fibrous layer of the pericardium, it is generally of a rheumatic character, 
and the symptoms which are developed are similar, in many respects, to 
those usually attending rheumatic inflammation of other fibrous struc- 
tures. 

If, again, as is more generally the case, the serous and fibrous mem- 
branes both become inflamed, the symptoms which attend are such as 
might be expected. And as the external or pleural covering of the peri- 
cardium is generally more or less involved in pericarditis, we have 
added some of the symptoms of common pleuritic inflammation. 

With these considerations, and bearing in mind the anatomy and phy- 
siology of the heart, and especially the structure and function of the 
pericardium, let us proceed to inquire into the symptoms of pericarditis ; 
and first of that variety involving mainly the serous layer of the peri- 
cardium. 

Symptoms. — Acute serous pericarditis generally commences with a 
chill, or slight coldness, with marked faintness. Very soon, however, 
febrile reaction is set up, the skin becomes hot, the pulse frequent, the 
urine scanty, and there is a coated tongue, with loss of appetite, &c. 

Sudden, severe, and lancinating pains are experienced, early in the 
disease, in the centre of the cardiac region, and extending in most cases 
to the epigastrium, and to the back between the shoulders. Along with 
the pain there is apt to be faintness, oppression, dyspnoea, palpitation of 
the heart, and a sense of constriction under the sternum, and in the left 
side of the thorax. There is also, in most cases, a distressing cough, 
with hurried respiration, vomiting, delirium, syncope, and, if the disease 
passes on, oedema of the face, and sometimes of the extremities. 

The patient is unable to lie on the left side, and greatly prefers the 
sitting posture, with the head and shoulders inclined forwards. The 
short, dry cough is apt to continue, and is attended with sudden feelings 
of distressing faintness, more or less, through the whole course of the 
disease. 

As the disease progresses, the pulse becomes irregular, intermittent, 
and almost imperceptible ; the face becomes pale, and the lips livid ; 
the speech is faltering, and the action of the heart becomes so feeble, 
that its impulse becomes almost imperceptible, and its sounds inaudible. 

Palpation detects, in the early stages of the disease, an increased 
action of the heart, which may also be confirmed by inspection . There 
is also tenderness on pressure in the intercostal spaces, and also in the 
epigastrium, if the pressure be directed towards the pericardium. 

Auscultation, as the disease becomes developed, detects a tumultuous, 
frequent, irregular, and sometimes intermittent action of the heart, cor- 
responding with the pulse at the wrist. But as lymph is thrown out, 
a simple rubbing sound is heard, or the sound may be harsh, grating or 
creaking, or it may resemble the bellows sound of the valves, in disease. 

Percussion over the heart, in the early stages of this disease, may 



490 DISEASES OF THE CIRCULATORY SYSTEM. 

elicit nearly a natural resonance, and it may continne nearly natural 
even after lymph is thrown out. But when effusion takes place, if that 
occurs, there is dullness on percussion, on the left side of the lower por- 
tion of the sternum, which gradually extends upwards. And in cases 
in which the pericardium becomes largely distended, the dullness extends 
in every direction, but especially transversely and inferiorly. 

In such cases, as the fluid increases in the pericardium, the impulse 
of the heart is gradually diminished, till at last it is nearly or quite 
lost. 

The rhythm of the heart becomes unnatural in this disease, varying 
in different cases from the treble beat to an utter confusion in the suc- 
cession of sounds. And finally, in cases in which the pericardial effu- 
sion becomes considerable, there is a decrease in the sounds of the 
heart, the sounds appearing distant, and in some cases becoming almost 
inaudible. 

Such, according to my observation, are the ordinary symptoms 
attending acute pericarditis, affecting mainly the serous layer of the 
pericardium. But rheumatic cases, which I believe consist, more espe- 
cially in inflammation of the fibrous layer of the pericardium, have 
some peculiarities, the symptoms of which it may be proper for us to 
notice, as we proceed. 

Rheumatic pericarditis, which occurs from metastasis of rheumatism 
from other parts, may be violent, and pass on rapidly to a fatal termina- 
tion, the fibrous membrane being especially, and the serous membrane, 
of course, more or less involved. In such cases, there is a dull but severe 
pain in the region of the heart, with irregularity of the heart's actions, 
an irregular pulse, difficult respiration, occasional faintness or syncope, 
and a livid appearance of the countenance. 

But when rheumatic pericarditis is not the result of metastasis from 
other parts, it may arise slowly, and the symptoms may be less violent. 
In such cases there is generally more or less fixed pain in the region of 
the heart, of a dull and distressing character, subject, however, to ex- 
acerbations, from even slight causes. There is some dyspnoea and 
oppression in the chest, and generally a short, dry cough ; the pulse is 
small, and at times irregular and intermittent, and the heart is liable 
to be thrown into violent paroxysms of palpitation by slight exertion, 
sudden mental excitement, &c. 

If the inflammation is confined entirely to the fibrous layer of the peri- 
cardium, there may be no effusion, and consequently no dullness on per- 
cussion in the prsecordial region. But if as generally happens in acute 
cases, and in protracted chronic cases the inner or serous coat of the 
pericardium becomes inflamed, effusion generally takes place into the 
pericardium, attended with dullness on percussion and most of the physi- 
cal signs already enumerated. 

Death in this disease sometimes occurs very suddenly and unexpected- 
ly. But more frequently there is a slow wasting of the body and de- 
clension of the vital powers, which gradually leads to a fatal termina- 
tion. 

Anatomical Characters. — The pericardium is generally found coated, 
as well as the heart, with coagulable lymph or false membrane. This 



PERICARDITIS. 491 

may be in layers or in shreds, or it may be in diffused patches on the 
surface of the heart and its investing serous membrane. 

A serous, sanguineous, sero-purulent, or purulent, effusion is generally 
found in the pericardium, varying in quantity from a few ounces to 
several pounds. The two surfaces of the pericardium may be adherent 
interrupting more or less the action of the heart. And in cases in which 
the heart itself has been involved, there is found more or less change in 
its appearance and structure, according to the nature and extent of the 
cardiac disease. 

In strictly rheumatic cases, involving exclusively the fibrous layer of 
the pericardium, I believe there is generally no pseudo-membranous exu- 
dation or serous or other effusion into the pericardium, and the surface 
of the heart may present a nearly natural appearance. 

Such I believe are the most frequent morbid appearances presented 
in fatal cases of pericarditis, liable of course to variations, as we have 
seen depending upon the nature and extent of the pericardial inflamma- 
tion. 

Diagnosis. — Pericarditis may be confounded with endocarditis, pleuri- 
tis, pneumonia, and perhaps gastritis. But there are sufficient diagnostic 
symptoms by which it may be distinguished from these, and all other 
affections. In fact it is only necessary to bear in mind the dull or lanci- 
nating pain in the region of the heart, extending to the back and epi- 
gastrium, the irregular action of the heart, with the irregularity, inter- 
mission and weakness of the pulse, the difficult respiration and tendency 
to syncope or faintness, the disposition to remain in the sitting posture 
with the head and shoulders forward, and finally the oedema of the face 
and extremities and dullness on percussion over the heart, &c, in order 
to distinguish this from all other affections. 

Rheumatic pericarditis may be distinguished from other cases by the 
general rheumatic condition or tendency of the patient, the dullness of 
the pain, and the fact of its metastasis from other parts, or its gradual 
development without many of the active symptoms which attend simple 
acute pericarditis. 

Causes. — Whatever is capable of producing inflammation of any of 
the thoracic tissues or organs, may give rise to simple pericarditis. 
Among the causes which thus operate to produce the disease, are sudden 
exposure to cold, the healing up of old ulcers, the suppression of habi- 
tual evacuations, repelled cutaneous eruptions, the use of tobacco and 
intoxicating drinks, depressing mental emotions, masturbation and exces- 
sive venery, and various abuses of the system. 

Rheumatic cases of pericarditis may occur from metastasis of the dis- 
ease from the extremities, or other parts, in consequence of a depression 
of vital power, caused by overdepletion or other depressing influences, 
or rheumatic cases may arise slowly, in consequence of some of the de- 
pressing influences already enumerated, such as masturbation, the use of 
tobacco, drunkenness, excessive venery, and other abuses of the system, 
in rheumatic constitutions. 

Prognosis. — The prognosis in pericarditis, except in very debilitated 
patients, or worn-down constitutions, is generally favorable. I believe 
that large a majority of rheumatic cases, and many others, terminate by 



492 DISEASES OF THE CIRCULATORY SYSTEM. 

resolution. If, however, in pericarditis there is great irregularity in 
the heart's action, as well as in the pulse, attended with dyspnoea, faint- 
ing, or syncope, a livid appearance of the countenance, and a large 
effusion takes place into the pericardium, a fatal termination may be 
apprehended. 

Treatment. — In very robust patients an acute attack of simple peri- 
carditis may occasionally call for general bleeding, but very rarely, I 
think. The feet should be placed in warm water, and a little warm sage 
tea allowed, with the hope of promoting perspiration. 

Cups should be applied at once over the heart, and also on each side 
of the spine between the shoulders, and a few ounces of blood taken, 
except in very anaemic or debilitated patients, in which case dry cups 
only should be applied. 

A cathartic of calomel or podophyllin should be given at first, in castor 
oil, and the bowels afterwards kept open by small doses of cream of 
tartar. After the operation of the cathartic, two grains of calomel and 
four grains of Dover's powder may be given, every four hours, till slight 
ptyalism is produced. The warm foot-bath should be repeated, morning 
and evening, and blisters applied between the shoulders, immediately after 
the operation of a cathartic, as well as dry cups over the region of the 
heart. 

After slight ptyalism is produced the calomel should be omitted, and 
the Dover's powder continued, with one grain of pulverized digitalis, 
every six hours, to quiet pain, promote perspiration, and to act gently 
on the kidneys. 

If, however, at this stage there is evidence of effusion into the peri- 
cardium, five grain doses of the iodide of potassium may be given, every 
six hours, alternating with the Dover's powder and digitalis, and con- 
tinued after the powders may no longer be required ; the bowels being 
kept loose by small doses of cream of tartar. 

The diet early, should consist of crust coffee, with a little milk, or 
arrow-root. But if the disease passes on, and becomes chronic, a moder- 
ately nourishing diet may be allowed. Drinks should be taken sparingly 
during the whole course of the disease, in order, if possible, to avoid 
effusion. In the latter stages of chronic cases, in ansemic patients, 
tonics may be indicated, and when they are, ten drops of the tincture of 
chloride of iron may be given, three times per day, after eating, in a 
wine-glassful of water. 

Blisters may sometimes be indicated, either over the region of the 
heart, or between the shoulders, and when they are — should not be 
omitted. 

In rheumatic pericarditis, of an acute character, especially that which 
results from metastasis of the disease from other parts, if the patient be 
plethoric, after the general bleeding, if indicated, the warm drinks, 
cupping, and cathartic should be resorted to, as well as the mercurial 
with Dover's powder, as in ordinary cases of simple pericarditis. But 
immediately after the operation of a cathartic, in such cases, if there is 
general febrile excitement, fifteen grains of the nitrate of potassa may 
be given, in a teacupful of warm crust coffee, every six hours, till the 
fever is subdued. This may be given, alternating with the Dover's pow- 



ENDOCARDITIS. 493 

der, and as the nitre is discontinued, ten grain doses of the iodide of 
potassium may he given, every six hours in its stead, and continued till 
the violence of the disease is subdued ; after which, it may he reduced 
to five grain doses, three times per day, and continued for a time. 

In rheumatic pericarditis, however, occurring in anaemic or debilitated 
patients, and coming on bj metastasis, or otherwise from debility, or 
some depressing influence ; general, or even local bleeding may not be 
admissible, and the nitre is not generally required. But after the foot- 
bath, dry cupping, cathartic, &c. the Dover's powder, and mercurial 
may be given, with the sulphate of quinine, and immediately after dis- 
continuing the mercurial, the iodide of potassium should be given, as 
already suggested, and continued till the disease is subdued, and its 
effects removed. 

The bowels may be kept gently loose by cream of tartar. Blisters 
may be required over the region of the heart; and should the disease 
pass on, and the pericardium become greatly distended, paracentesis may 
be performed, as a last resort. 

SECTION III.— ENDOCARDITIS. 

By endocarditis, is here meant inflammation of the endocardium, or 
lining membrane of the heart; including generally its folds, the valves, 
as well as the fibrous layer which gives them strength, and the chordse 
tendinese, by which they are held in place. 

The lining membrane of the heart, or endocardium, it will be remem- 
bered, is a serous membrane, continuous with the lining of the arteries 
and veins. 

The endocardium, in the right side of the heart, besides lining the 
auricle and ventricle, forms folds constituting the semilunar valves, at 
the commencement of the pulmonary artery. It also, by three other 
folds, forms the tricuspid valve, by the help of a fibrous layer to afford 
strength, and the chordse tendinese to prevent their being driven back by 
the reaction of the blood, on the contraction of the ventricle. 

In the left side of the heart the endocardium besides lining the auricle 
and ventricle has folds constituting the semi-lunar valves at the com- 
mencement of the aorta, and also two folds forming the mitral valve by 
the aid of a fibrous layer and the chordse tendinese. The fibrous layer 
of the mitral valve gives strength, and the tendinous chords prevent 
the valve from being driven back by the reaction of the blood on 
contraction of the ventricle, as in the case of the tricuspid valve at the 
right auriculo-ventricular passage. The endocardium thus situated and 
constituted, is liable to become inflamed, the symptoms of which we will 
now proceed to consider. 

Symptoms. — Inflammation of the lining membrane of the heart com- 
mences with a feeling of anxiety in the region of the heart, and perhaps 
slight chilliness, followed by fever, with a strong, full and excited pulse. 

The disease is attended with very little pain, but the valves soon be- 
come thickened, or coagula form, which interfere with the free movement 
of the blood ; in consequence of which the heart contracts rapidly, the 
pulse being in some cases so frequent as scarcely to be counted, as well 
as small and feeble. 



494 DISEASES OF THE CIRCULATORY SYSTEM. 

In consequence of the interruption to the free passage of blood through 
the heart, arterial blood is not supplied in sufficient quantity to the 
system generally, and the lungs, right cavities of the heart and venous 
system become more or less congested. As a consequence of all this, 
there are frequent faintings or syncope, paleness or lividity of the coun- 
tenance, distressing dyspnoea, aggravated by exercise or mental emotion ; 
the patient evinces great anxiety, cold sweats break out, and finally, if 
the disease passes on, the mind becomes wandering, coma or convulsions 
supervene, and the patient dies in a state of general oedema. 

Palpation detects, early in the disease, an increased impulse of the 
heart; which, however, as the disease progresses, gradually becomes 
feeble. 

Percussion elicits a dull sound over an extended surface, probably in 
part from "turgescence of the walls of the heart," but more especially 
from distention of its cavities. 

Auscultation detects an unnatural rhythm of the heart, varying 
according to the degree of interruption to the free passage of the blood 
through the organ. In some cases there may be detected the treble beat, 
but in advanced stages of bad cases there is often an utter confusion in 
the succession of sounds. The ear also detects a murmur caused by im- 
perfection of the valves, and also in part by a roughness or partial 
closure of the auriculo-ventricular, aortic, and pulmonary passages. 
The murmur may be a soft bellows sound, or it may be the rough or 
harsh rasping or saiving murmur ; or it may resemble the tone of musical 
instruments, according to the degree of roughness of the passages and 
leakage of the different valves. 

In the early stage of the disease, the sounds of the heart may be con- 
siderably increased, but in the latter stages, as the power of the heart 
muscle becomes exhausted, the second sound of the heart may be nearly 
lost, or obscured by the murmur that attends. 

Such, I believe, are the ordinary symptoms of endocarditis ; liable, of 
course, to variations, as is the case in all other affections. 

Diagnosis. — Endocarditis may be confounded with pericarditis, from 
which it should be distinguished, however, by attention to the following 
differences. 

In pericarditis there is either an acute and lancinating, or a dull, 
heavy pain in the region of the heart ; while in endocarditis there is 
little or no pain. In endocarditis there is the valvular murmur, and 
generally a continuance of the first sound of the heart ; while in peri- 
carditis there is an absence of the valvular murmur, and ultimately 
great diminution, or utter loss of both sounds of the heart. 

Finally, in endocarditis, though there is dullness on percussion, over 
an extended surface, the extent of surface affording a dull sound is by 
far less extensive than in pericarditis, attended with copious effusion. 
The two diseases may, however, be associated, in which case there may 
be noticed the valvular murmurs, in connection with the ordinary symp- 
toms of pericarditis. 

Anatomical Characters. — There is generally found redness of the 
membrane, often thickening, and occasional softening, with roughness or 
inequality, from fibrinous exudation. This fibrinous matter may be 



ENDOCARDITIS. 495 

found in layers, or in granulations on any part of the membrane ; but 
especially on the valves. 

In a ease that I examined in this village, a few years since, there was, 
in addition to the above appearances, an utter confusion in the appear- 
ance of the valves. They were thickened, distorted, and irregular in 
appearance, the tendinous cords were contracted, and the cavities of the 
heart presented altogether an unnatural or deranged appearance. 

It is probable that the exudation upon the valves, in protracted cases 
of this disease, may assume a cartilaginous or bony character, and thus 
leave permanent disease of one or more of the valves, especially of the 
mitral or semilunar, or both. 

Causes. — Various causes may produce endocarditis, among the most 
frequent of which are exposure to cold and dampness, the metastasis of 
rheumatism, the extension of phlebitis and arteritis, mechanical violence, 
rupture of the valves, from violent coughing, &c, urea in the blood, and 
various abuses of the system, such as masturbation, gluttony, drunken- 
ness, licentiousness, &c. The disease is liable to arise, from slight causes, 
in persons of rheumatic constitutions, and it is probably, in many cases, 
of a strictly rheumatic character. 

Prognosis. — The prognosis in endocarditis is rather favorable, as most 
cases recover under proper treatment. 

In severe cases, however, in which there are violent palpitations, with 
dyspnoea and syncope, or faintness, irregularity, frequency and feeble- 
ness of the pulse, and a livid countenance, with general oedema, a fatal 
termination may be apprehended. 

In cases in which most of the symptoms subside, leaving the valvular 
murmurs, danger may reasonably be apprehended of a permanent 
disease of the valves. But it is probable that the exuded lymph, in such 
cases, is sometimes gradually absorbed, and thus a permanent cure 
effected. 

Treatment. — Immediately on an attack of endocarditis, if the patient 
is vigorous and plethoric, a few ounces of blood may be taken from the 
arm, but not in anaemic cases. Immediately after general bleeding when 
it is required, and at first when it is not, wet or dry cups, according to 
the strength of the patient, should be applied over the region of the 
heart, and on each side of the spine between the shoulders. 

The warm-foot path should be used, and a little warm sage tea allowed 
as drink. A cathartic of calomel or podophyllin, should be given in 
castor oil, and the oil repeated if necessary. After the operation of the 
cathartic, two grains of calomel, with four grains of Dover's powder 
should be given every six hours, unless the patient be anaemic, and con- 
tinued till slight ptyalism is produced. The warm foot bath should be 
repeated morning and evening, and a blister applied over the region of 
the heart, or on each side of the spine between the shoulders if neces- 
sary. 

In cases in which the mercurial is given, it should be discontinued as 
soon as slight ptyalism is produced, and Dover's powder continued if 
necessary, with a grain of pulverized digitalis, as long as an anodyne is 
required. 

The bowels should be kept moderately loose by small doses of cream 
of tartar, after the first cathartic, as it acts gently on the kidneys. 



496 DISEASES OF THE CIRCULATORY SYSTEM. 

Immediately on discontinuing the mercurial when it is indicated, and 
on the operation of the first cathartic in cases in which a mercurial im- 
pression is not required, ten grain doses of the iodide of potassium should 
he given every six hours, and continued till the bellows or other valvular 
murmurs subside. 

Early in acute cases, crust coffee with a little milk should be given for 
nourishment, but later in the disease, and in chronic anaemic cases, a 
good nourishing diet may be allowed. 

SECTION IV.— CARDITIS. 

By carditis, from xapfoa, " the heart," and the termination itis, I mean in- 
flammation of the fleshy substance of the heart, including its muscular 
and connecting cellular tissue. 

The heart it will be remembered is a muscle so arranged as to form 
its different cavities, the muscular fibres being intermingled with cellular 
tissue. There are three layers of fibres, an external, middle, and inter- 
nal, curved around each of the cavities of the ventricles, while the auri- 
cles have but two layers, an external and internal. 

The heart is supplied with blood by the anterior and posterior coronary 
arteries, and its nerves are derived from the cardiac plexuses, which are 
formed by filaments from the pneumogastric and sympathetic. "Its 
lymphatics terminate in the glands about the root of the heart." 

The heart thus constituted, and situated in the thorax between the 
two layers of pleura, constituting the mediastinum, is liable to become 
inflamed. Such an occurrence however is probably quite rare, no more 
than one well marked case having fallen under my observation, and that 
of a rheumatic character. The disease when it does occur, is attended 
with a train of symptoms which we will now proceed to consider. 

Symptoms. — When carditis is fully established, whether as an original 
affection, or arising during the progress of some other disease, there is 
great soreness and pain in the heart, a frequent and irregular pulse, 
dyspnoea, faintness, lividity, prostration, &c. In the case that fell under 
my observation, the pain in the heart was continuous, but it appeared to 
be piercing at each contraction of the heart, and so distressing was this 
that the heart would appear in consequence to almost cease to act for a 
time. During this cessation in the heart's actions, there was dyspnoea, 
faintness, and lividity, with cold sweats, and the sensibility of the sys- 
tem would sink so low as apparently to render the patient unconscious 
of pain, when the heart would again resume a sort of spasmodic action 
for a time. Thus the symptoms continued for about forty-eight hours, 
after the supervention of the cardiac inflammation, when the heart be- 
came unable or utterly refused to act, thus putting an end to the most 
distressing train of symptoms I ever witnessed. 

Auscultation detects an unnatural rhythm, with apparent intermis- 
sions in the heart's actions, the impulse and sounds of the heart being 
at one moment increased, and very soon greatly diminished, or entirely 
imperceptible. 

In cases in which the carditis occurs as an original affection, it may 
be ushered in with a chill, followed by an irregular febrile reaction ; but 



CARDITIS. 497 

I believe the disease more frequently arises during the progress of rheu- 
matic or other inflammatory affections. 

Diagnosis. — Carditis may be distinguished from endocarditis by the 
pain, by the absence of valvular murmurs, and by the much greater 
irregularity of the pulse, in the early stage of the disease, than is com- 
mon in endocarditis. 

From pericarditis this disease may be distinguished by careful atten- 
tion to all the symptoms, and especially by the absence of signs of peri- 
cardial effusion. It is probable, however, that the pericardium, endocar- 
dium, and muscular tissue of the heart, may occasionally be all involved 
in a general inflammation, of an active or passive character, in which 
case there may be a combination of the symptoms enumerated as belong- 
ing to each. 

Causes. — Carditis may arise from a great variety of causes, among the 
most frequent of which are sudden exposure to cold, a rheumatic condi- 
tion, the use of tobacco, drunkenness, masturbation and excessive venery, 
gluttony, starvation, or any influence, either physical or moral, which is 
capable of producing either a plethoric or anaemic condition of the sys- 
tem ; in the one case the inflammation being of an active, and in the 
other of a passive character. 

Anatomical Characters. — The muscular tissue of the heart may be 
found of a very dark red color, softened, and more or less infiltrated 
with a bloody purulent matter, or filled with small abscesses containing 
pus. 

Other morbid appearances may occasionally be presented, but the 
above I believe are the most frequent. It is probable, however, that 
carditis is sometimes the cause of hypertrophy and induration, as well 
as of "cartilaginous and osseous transformations."* 

Treatment. — In carditis, in which the inflammation is of an active 
character, general bleeding, and by cups, warm pediluvia, cathartics, 
mercurials, anodynes, and diaphoretics constitute the treatment proper. 

A moderate general bleeding may be followed by cups between the 
shoulders, and over the region of the heart. The feet should be placed 
in warm water, and warm sage tea allowed at first. 

Calomel should be administered with castor oil, and after its operation, 
in severe cases, a slight mercurial impression should be produced, and, 
if necessary, blisters applied over the region of the heart, and between 
the shoulders. 

In carditis, in which the inflammation is of a passive character, dry 
cups, warm pediluvia, mild cathartics, blisters, Dover's powder, with the 
sulphate of quinine, and a reasonable amount of food, are to be mainly 
relied upon. 

In rheumatic cases, in addition to the treatment already suggested, 
full doses of the iodide of potassium should be given, every six hours, 
after the operation of the cathartic, or completion of the mercurial 
course, in cases in which that is indicated. In active cases it may be 
given with twenty drops of the wine of colchicum ; but in passive cases 
it should be given alone, alternating with Dover's powder and quinine. 

* See Dickson's Elements of Medicine, p. 340. 

32 



498 DISEASES OF THE CIRCULATORY SYSTEM. 

SECTION V.— ORGANIC DISEASES OF THE HEART. 

Under the head of organic diseases of the heart, I design to include in 
this section, hypertrophy, dilatation, diseases of the valves, aneurism of 
the aorta, and rupture of the heart; giving first the general characters 
of organic cordiac disease, and then those peculiar to each variety. 

It will be remembered that the right auricle on receiving the venous 
blood from the ascending and descending cavae contracts, forcing the 
blood through the right auriculo-ventricular passage into the right 
ventricle. The left auricle receives the arterial blood from the lungs 
through the pulmonary veins and contracts at the same time with the 
right auricle, passing the blood on through the left auriculo-ventricular 
passages into the left ventricle. Now both ventricles being filled with 
blood at the same time they contract together ; which contraction, to- 
gether with the reaction of the blood upon the tricuspid and mitral valves 
produce the first sound of the heart. 

The blood of the right ventricle passes during this contraction into 
the pulmonary artery, and the blood of the left ventricle passes into the 
aorta. The pulmonary artery and aorta now contract, and this contrac- 
tion, together with the reaction of the blood upon the semi-lunar valves, 
causes the second sound of the heart. 

If, now, as we have already seen, the first sound, the second sound, 
and the interval be divided into fifths, the first sound will occupy two- 
fifths, the second sound one-fifth, and the succeeding interval the remain- 
ing two-fifths ; "and this regular division of the time occupied by one 
complete circuit of the heart's functions constitutes the rhythm of the 
organ." 

"The time occupied by the whole corresponds to the time between one 
stroke of the pulse and another ; so that if a person's pulse beat eighty 
times in a minute, there would be eighty long sounds, eighty short sounds, 
and eighty intervals." 

If the hand be placed on the left side of the chest below the nipple, in 
the space between the fifth and sixth ribs, a little to the inner side of a 
line running vertically over the nipple, a gentle regular pulsation is felt, 
and a slight shock is perceived. "This is the impulse of the heart," and 
is caused by the impinging of its apex against the parieties of the chest, 
is nearly synchronous with the pulse at the wrist, and with the contrac- 
tion of the ventricles, as we have already seen. 

Such, then, is the heart, its impulse, rhythm and sounds in a healthy 
state ; but when the heart becomes diseased or deranged in its functions, 
a train of morbid sounds, impulses, &c. arise, each of which indicate, to 
a certain extent, the peculiar condition of the suffering organ. 

The heart is liable, as we have seen, to organic disease, embracing 
hypertrophy, dilatation, diseases of the valves, and rupture of the organ ; 
the general character of which we will first consider, and then proceed 
to inquire into the peculiarities of each. 

General Symptoms. — The general symptoms of organic disease of the 
heart are what might be expected when we take into account the general 
structure and function of the organ as well as the organic changes to 
which it is liable. 



ORGANIC DISEASES OF THE HEART. 499 

The countenance in confirmed cases of organic cardiac affections, has 
generally a peculiar anxious expression ; the face is pale, with lividity 
of the prolabia, and besides the labial trait, there is often a puffy swell- 
ing under the eyes. 

The respiration is unnatural, the inspiration being either very quick 
and wheezing, or the patient breathes as though he had been walking 
rapidly, or, finally, the respiration may be short, the air not appearing 
to enter the lower portion of the lungs. Mental excitement, or cor- 
poreal exertion, such as walking up hill, or ascending a flight of 
stairs, is always liable to bring on paroxysms of dyspnoea. 

In some cases, very trifling physical or mental excitement gives rise to 
suffocative breathing, with a feeling of constriction in the breast, great 
anxiety, a turgid and livid hue of the face, and especially of the lips, 
and, finally, distention of the veins of the neck, and an expression of 
distress and great suffering in the countenance. 

The action of the heart is always deranged. In some cases it labors 
tumultuously, while in others it is in a state of tremulous agitation. 
More generally the impulse of the heart is very distinct, so as to com- 
municate a motion to the whole superior part of the body. Sometimes, 
however, it becomes entirely imperceptible, for a time at least. 

The rhythm of the heart becomes often unnatural, varying from the 
treble beat to more or less confusion in the succession of sounds. 

The sounds of the heart may remain nearly natural, but generally 
they are either morbidly increased or diminished, and in some cases 
they become quite inaudible. The patient is liable to partial faintings, 
of long continuance, attended with great oppression in the region of the 
heart, a partial loss of consciousness, great anxiety in the prgecordia, 
with a feeble, fluttering or intermittent pulse, and but slight perceptible 
respiration. 

In the worst cases the patient is sometimes obliged to remain days 
and nights in the sitting posture, any attempt to lie down being followed 
by the most distressing paroxysms of palpitation and dyspnoea. 

After organic disease of the heart has continued for some time, there 
is generally a dropsical tendency, with more or less swelling of the feet, 
and in the latter stages, effusion into the chest or pericardium. This 
may readily be accounted for, when we remember the imperfection of 
the circulation, and consequent congestion of the venous and capillary 
system of vessels. 

Such, according to my observation, are the symptoms common to 
most organic diseases of the heart, being sufficient generally to justify a 
more close examination, to ascertain, if possible, the exact morbid con- 
dition of the suffering organ. 

Diagnosis. — Organic may generally be distinguished from sympa- 
thetic affections of the heart, by careful attention to the following 
symptoms. 

In organic disease, there is dyspnoea, with an anxious expression of 
the countenance, lividity of the lips, and in many cases the labial trait, 
consisting, as we have seen, of a slight depression extending from the 
angle of the lips to the margin of the chin, none of which symptoms are 
necessarily connected with sympathetic cardiac affections. 



500 DISEASES OF THE CIRCULATORY SYSTEM. 

In organic disease, there is irregular action of the heart, involving 
derangement in its impulse, rhythm and sounds, as well as an irregular 
and generally intermittent pulse, while in sympathetic affections of the 
heart, the derangement in the heart's action is less marked, and the 
pulse is seldom intermittent. Finally, in organic disease, the patient 
has great difficulty in ascending a flight of stairs, or walking up hill, 
and in the latter stages, there is apt to be more or less dropsical effusion 
either into the cellular tissue, or into the serous cavities, none of which 
symptoms are common in sympathetic cardiac affections. 

Causes. — A great variety of causes may operate, either directly or 
indirectly, to produce organic diseases of the heart, among the most 
frequent of which are carditis and endocarditis, a rheumatic condition 
of the system involving the heart ; long continued anxiety of mind, the 
metastasis of cutaneous diseases ; a syphilitic taint, and perhaps also 
an hereditary predisposition. Organic diseases of the heart are also 
produced by various abuses of the system, such as masturbation, exces- 
sive venery, the use of tobacco, intoxicating drinks, gluttony, starvation, 
and various other deviations from the laws of health. 

I am satisfied, however, that by far the most frequent causes of organic 
diseases of the heart are, a rheumatic condition, masturbation, and ex- 
cessive venery, and the use of tobacco, either by chewing, smoking, or 
snuffing. 

Prognosis. — The prognosis in all organic diseases of the heart is un- 
favorable, yet by careful and judicious management many cases may be 
so far palliated as to allow the patient to live on for several years. This 
wull depend, however, very much upon a strict observance of the laws of 
health on the part of the patient, and conformity to the rules of pro- 
priety in every respect. It should be remembered, however, that with 
all due prudence, the patient is liable to be taken away, at any moment, 
in advanced stages of organic cardiac disease. 

Let us now inquire into the characters peculiar to each variety of 
organic disease of the heart, and then we shall be prepared to suggest 
the treatment proper for each ; and, first, of hypertrophy. 

HYPERTROPHY OF THE HEART. 

By hypertrophy of the heart, I mean here " an overgrowth of the 
organ;" consisting in thickening of its walls, with or without contraction 
or dilatation of its cavities. 

It appears to be a law of the animal economy that action, within cer- 
tain limits, increases its growth ; and especially is it the case, that an 
increased action of a muscle increases its bulk and strength. This rule 
applies to the heart, which is a hollow muscle ; so that when obstruction 
exists to the free passage of blood through the organ, or the action of 
the heart is increased, from any cause, the muscular tissue may increase 
to two or three times its natural weight. 

Symptoms. — In simple hypertrophy of the heart, without contraction 
or dilatation of its cavities, there is, in addition to the general symptoms 
of organic disease of the heart, a powerful and heaving impulse. If, 
however, there is dilatation with the hypertrophy, or thickening, the im- 
pulse is not only powerful, but diffused ; being sometimes felt over the 
whole precordial region. 



ORGANIC DISEASES OF THE HEART. 501 

Obstruction in the pulmonary artery or mitral valve, by producing 
increased action of the right ventricle, sometimes leads to hypertrophy 
of that portion of the heart, in which case there is an increased impulse, 
especially in the scrobiculus cordis. 

Or if the mitral valve remains inefficient for a long time, the whole 
heart, except the left ventricle, may become hypertrophied, with or with- 
out dilatation, in consequence of increased action of the organ. In such 
cases, in addition to the increased impulse at the scrobiculus cordis, there 
is an increased impulse between the cartilages of the third and fourth 
ribs. Finally, in cases in which there is obstruction in the aortic valves, 
or in the arch of the aorta, the left ventricle is liable to become especi- 
ally hypertrophied, along with the whole heart, and the increased im- 
pulse may be more perceptible below the nipple, a little to the left of the 
sternum. 

In cases, however, in which the hypertrophy is from other causes than 
valvular disease, it is usually general, and if there is no dilatation the 
impulse is felt, strong and heaving, below the left nipple. But if with 
the hypertrophy there is dilatation, the impulse, as we have seen, may be 
felt over the whole precordial region. 

The rhythm of the heart, in cases not dependent upon valvular dis- 
ease may remain quite natural, but in cases that arise from valvular ob- 
structions, or imperfections, there is a disturbed rhythm, depending upon 
the character and extent of the valvular disease. 

The sounds of the heart in dilatation, vary according to the condition 
of the organ. If with the hypertrophy, there is no dilatation, but rather 
a contraction of the cavities; the sounds of the heart may not be in- 
creased ; hut perhaps slightly diminished. If, however, with the hyper- 
trophy, there is more or less dilatation, the sounds may be increased. The 
sounds in either case, may, however be obscured, by direct, or regurgi- 
tating murmurs, in cases of hypertrophy dependent upon, or connected 
with organic valvular disease. 

Such, I believe, are the symptoms peculiar to hypertrophy of the 
heart. And it should be remembered, that while hypertrophy of the 
heart, is generally connected with, and dependent upon a deranged con- 
dition of the system, and valvular imperfection ; the condition may arise 
independent of those causes, and apparently from a strong, vigorous, and 
robust condition of the system, at least so far as can be discovered. 

Diagnosis. — Hypertrophy of the heart, with or without dilatation, may 
be distinguished from simple dilatation, by careful attention to all the 
symptoms, and by the following differences: In hypertrophy, with or 
without dilatation, the sounds may be nearly natural, or but slightly in- 
creased; but there is a powerful and heaving impulse, while in simple 
dilatation, without hypertrophy, the impulse is weak, but the sounds may 
be morbidly increased. 

Finally, hypertrophy may occur in strong robust subjects; while sim- 
ple dilatation generally occurs in anaemic, weak, and feeble patients. 

DILATATION. 

By dilatation, I mean here, an increase in the bulk of the heart, with 
proportional "attenuation of its parietes," and consequently no hyper- 
trophy, 



502 DISEASES OF THE CIRCULATORY SYSTEM. 

This form of organic cardiac disease, generally occurs in anaemic, 
weak and feeble subjects, or those in whom the muscular system is in a 
weak and relaxed condition. 

Symptoms. — In cases of simple dilatation of the heart, the symptoms 
do not differ widely from those which attend dilatation, with hypertrophy. 
The patient generally, however, has a pale anaemic appearance, a feeble 
pulse, and is subject to paroxysms of distressing, tremulous palpitation. 

The impulse of the heart in simple dilatation, is generally weak. But 
if the dilatation is considerable, the impulse may sometimes be felt over 
a larger extent of surface than in health. 

The rhythm of the heart is always more or less disturbed; while the 
sounds are apt to be morbidly increased. The sounds, however, are 
liable to be obscured by direct or retrograde murmurs, caused by disease 
in, or leakage of the valves. Percussion elicits a dull sound, over an 
extended surface in the precordial region, and this increased dullness 
may be general, in this region; or it may be most marked over some 
particular portion of the heart, if the dilatation of one cavity is more 
than of another. 

In case the left ventricle is especially dilated, the dullness is most 
marked below the left nipple, over the costal cartilage. If the left 
auricle is mainly dilated, the increased dullness is most conspicuous on 
the third and fourth ribs and their cartilages to the left of the sternum. 
If, however, it is the right ventricle that is especially involved in the 
dilatation, the increased dullness will be most apparent to the right of 
the sternum, at the inner edge of the right mammary region and at the 
scrobiculus cordis. 

Such, according to my observation, are the most prominent symptoms 
peculiar to simple dilatation of one or all the cavities of the heart ; by a 
careful observation of which, the real condition may generally be very 
nearly ascertained. 

DISEASE OF THE VALVES. 

Another variety of organic cardiac affection consists in a chronic dis- 
ease of the valves, involving, in some cases one, and in others several or 
all the valves connected with the heart, but more frequently the mitral 
and semi-lunar, the tricuspid being more rarely involved. 

The valvular disease may consist in mere thickening, or the edges of 
the valves may be united by inflammation, so as to narrow the passage ; 
or the valves may contract adhesions, or the tendinous chords become 
lengthened or shortened so as to prevent the possibility of an accurate 
closure of the valves. But in protracted cases, the fibrous layer of the 
valves is very liable to become thickened, indurated, and finally con- 
verted into fibro-cartilage or bone, thus rendering the free motion of the 
valves, and disqualifying them for the due performance of their function. 

Or, instead of this transformation of the fibrous tissue into fibro-cartil- 
age or bone, there may be a calcareous or steatomatous deposition be- 
neath the serous membrane, forming masses of considerable size, leading 
to inflammation, ulceration, and final rupture of the valves, and conse- 
quent fissures of greater or less extent. 

Finally, fleshy, warty, or cartilaginous excrescences, of various sizes, 
the result of endocarditis, may form on the valves, or on the endocardium 



ORGANIC DISEASES OF THE HEART. Olid 

along the passages at the seat of the valves, which not only interfere with 
the free action of the valves, but also hinder the free current of blood 
along the passage. 

The valves, too, may become atrophied, or in case of considerable 
dilatation of the heart, may become too small for the passage they were 
designed to close ; in either case, allowing a regurgitation of the blood 
when a perfect closure should have been effected. 

The mitral, and semi-lunar valves at the commencement of the aorta, 
are the ones most frequently affected ; but the tricuspid and pulmonary 
are occasionally involved, as we have already seen. 

Symptoms. — The symptoms of chronic valvular disease embrace all or 
nearly all before enumerated as belonging to organic diseases of the 
heart. There is often symptoms of carditis or endocarditis preceding the 
valvular disease, and in most cases a rheumatic condition of the system, 
connected with, if not always acting as cause, either predisposing or ex- 
citing, of the valvular disease. So, too, the impulse, rhythm and sounds 
of the heart are more or less deranged, as in dilatation and hypertrophy, 
and the pulse irregular, and often intermittent. 

The symptoms, however, which are especially peculiar to chronic val- 
vular disease, are the direct and regurgitating murmurs which arise, the 
one from partial interruption to the free passage of the blood, and the 
other from a leakage of the valves, in consequence of some one of the 
morbid conditions of the valves or endocardium, already referred to. 

The morbid sounds or murmurs, both direct and retrograde, thus pro- 
duced, vary according to the nature and extent of the valvular disease. 
In some cases the sound is the soft " bellows murmur" the "bruit de 
souflet ;" in others it is the harsher or "rasping murmur" the "bruit 
de rape ;" or it maybe the harsh or grating " sawing murmur " the 
"bruit de scie ;" or finally, the murmur may resemble the tone of musi- 
cal instruments, constituting the "musical sound." 

If now a direct murmur exists in one valve, and a retrograde murmur 
in another, they may appear single as to time, but they may generally 
be distinguished by their location. If, however, a murmur arises from 
the direct and retrograde passage of the blood through the same valve 
or corresponding pair of valves, the murmur is double, because it occurs 
at different times. 

To ascertain which of the valves are involved, care should be taken 
to get at the seat of the murmurs which arise, and then by recollecting 
the location of the valves, a correct conclusion may generally be drawn, 
in relation to the nature and seat of the disease. 

In case regurgitation takes place through the aortic valves, a murmur 
is heard over the sternum, a little below the third rib. This murmur 
occupies the time of the second sound of the heart, which it may con- 
ceal. " If, however, there is both obstruction in, and regurgitation 
through the aortic valves, a double murmur or see-saw sound is heard 
over the sternum, opposite the third rib." This sound may be heard 
along the course of the aorta, but less distinctly as the ear is passed 
from over the aortic valves. Disease of the aortic valves is generally 
attended with more or less throbbing of the arteries, and a " peculiar 
jurking pulse." 



504 DISEASES OF THE CIRCULATORY SYSTEM. 

Should regurgitation take place through the pulmonary valves a mur- 
mur is produced, occupying the time of the second sound of the heart ; 
and should there also be a direct obstruction, the double murmur will be 
heard, as in the same condition of the aortic valves ; but the murmur will 
be heard nearly opposite the cartilage of the third rib, to the left of the 
sternum. The murmur is heard for a little distance up the pulmonary 
artery, but not along the aorta, and there is not the jerking pulse or 
throbbing of the arteries which attend in disease of the aortic valves. 

In case regurgitation takes place through the mitral valve, the mur- 
mur occupies the time of the first sound of the heart, and is most dis- 
tinctly heard between the cartilages of the fourth and fifth ribs, a little 
to the left of the sternum, and below the nipple. It may also be audi- 
ble in the axilla, and close by or upon the spine, in the interscapular 
region. 

In case direct obstruction exists, the murmur is heard in the same 
position, but it is comparatively feeble, and occupies the time of the 
second sound of the heart instead of the first. 

The tricuspid valve is seldom the seat of disease, but when it is 
the regurgitating murmur occupies the time of the first sound of the 
heart, and the direct murmur the time of the second, the murmurs being 
heard most distinctly over the lower part of the sternum. Disease of 
this valve is attended with distension, and sometimes visible pulsation 
of the jugular veins, which may aid in pointing to the seat of the cardiac 
disease. 

ANEURISM OF THE AORTA. 

Closely connected with organic cardiac disease is aneurismal dilatation 
of the aorta. It may occur in the ascending, in the arch, or in the de- 
scending portion, but more frequently I believe in the ascending portion. 

Symptoms. — The general symptoms of this disease are mainly those 
belonging to organic diseases of the heart. Sometimes, however, these 
aneurismal tumors acquire a large size, compressing the trachea, bron- 
chia, oesophagus, and even displacing more or less the heart itself. They 
also frequently produce murmurs similar to those produced by the direct 
and retrograde passage of the blood through diseased valves. And there 
is marked dullness on percussion over the aneurismal tumor. 

Diagnosis. — Aneurism of the aorta may be distinguished by the pre- 
sence of the bellows, rasping, or sawing murmurs over the seat of the 
disease. If the aneurism is of the ascending portion, or of the arch, it 
may be distinguished in most cases, by dullness on percussion in the 
upper sternal and subclavian regions. But if the aneurism exist in the 
descending portion, and is of large size, it may be detected by dullness 
on percussion along the left side of the spine, and in case it projects for- 
ward, dullness may be perceptible " in the prsecordial region." 

Such then, according to my observation, are the general symptoms of 
organic diseases of the heart, and also the peculiar symptoms and char- 
acters of hypertrophy, dilatation, diseases of the valves, and aneurism 
of the aorta, there being only left for our consideration, rupture of the 
heart, and finally a few suggestions in relation to the treatment of or- 
ganic cardiac diseases. 



ORGANIC DISEASES OF THE HEART. 505 

RUPTURE OF THE HEART. 

Rupture of the heart is a very rare, interesting and singular affection. 
If complete, it sooner or later fills the pericardium with blood, and pro- 
duces death, if not otherwise, by pressure upon the heart which sus- 
pends its action. 

The left ventricle appears to be the most frequent seat of the rupture, 
but it may occur in any part of the heart. And it may occur without 
any apparent disease of the organ from violent mental emotions, or from 
extraordinary physical exertion. 

Symptoms. — The symptoms are a sudden uneasiness or pain in the 
heart, followed by dyspnoea, syncope, and sudden death ; or these symp- 
toms may continue on, with irregular action of the heart, and an irregu- 
lar intermittent pulse, for a few hours, or a day or two, when death takes 
place, by a cessation of the heart's actions. 

A case of rupture of the heart fell under my observation a few years 
since, in Jefferson county, in this State. It occurred in a middle-aged 
lady, of rather feeble or slender constitution, and apparently from an 
effort she made to toss her child playfully above her head. At the mo- 
ment of doing this, she felt some pain and uneasiness in the region of 
the heart. The uneasiness continued to increase, with irregular palpi- 
tations, slight dyspnoea, and giddiness, for the succeeding forty-eight 
hours, at which time she suddenly died. 

I examined the body, in company with Drs. Webb and Whitmore, of 
Adams, N. Y., and found the heart completely enveloped with a firm 
coagulum of blood, the patient having evidently died from mechanical 
pressure of the blood on the heart, suspending its functions. The rup- 
ture was of the right auricle, and the result of an ulceration, which had 
partially perforated its walls. It was about the size of a crow-quill, its 
edges being, as is usual in such cases, rough and ragged. 

Such, then, are organic diseases of the heart, the general and par- 
ticular characters of which I have attempted thus imperfectly to trace. 

There remains now, in conclusion, a few suggestions to be made, in 
relation to the general and particular treatment of these diseases, which 
will close what I have to say on this subject. 

Treatment. — The general treatment proper for organic diseases of the 
heart, including aneurism of the aorta, consists mainly in subjecting the 
patient to a strict observance of the laws of health, in every respect. 
And this should have reference to food, clothing, exercise, temper of 
mind, and, in short, everything that can have an influence on the health 
of the patient. 

In plethoric cases, exercise, low diet, saline cathartics, &c, may be 
indicated. But in anaemic cases, moderate exercise, a nourishing diet, 
and tonics may be required, and when they are, should be adapted to 
suit each particular case. 

In hypertrophy of the heart, in addition to low diet, saline cathartics, 
and a reasonable amount of exercise ; if the patient is very plethoric, 
general bleeding may occasionally be required, but not generally I think. 
Blood may be taken by cups occasionally, however, in most cases of 
hypertrophy, with very good effect, not only from the region of the 
heart, but also from the left interscapular region. 



506 DISEASES OF THE CIRCULATORY SYSTEM. 

In simple dilatation of the heart, attended, as it generally is, with an 
anaemic condition, and a relaxed and debilitated slate of the muscular 
system, moderate exercise, a good nourishing diet, and tonics, may be 
required. For the blood, some preparation of iron is usually indicated, 
and generally I think the tincture of the chloride, in ten drop doses three 
times per day, will be found to do best. 

In cases in which there is great nervous prostration, in addition to 
the chalybeate, gV of a grain of the muriate of strychnia may be given, 
three times per day, for a time with good eifect. A grain of the mu- 
riate may be dissolved in eight ounces of water, of which a teaspoonful 
should be given three times per day. 

In disease of the valves, any lingering cardiac inflammation should be 
subdued, by cups, wet or dry, over the heart or between the shoulders ; 
and if necessary, blisters, or pustulation by tartar emetic, should be re- 
sorted to. In all rheumatic cases the iodide of potassium should be 
given in five grain doses, three times per day, and continued for a long 
time. 

Finally, in all organic diseases of the heart, and in aneurism of the 
aorta, in which there is a frequent and irregular pulse, unless great de- 
bility contra-indicates, the tincture of digitalis may be given in ten drop 
doses, three or four times per day, w T ith very good effect. 

SECTION VI.— SYMPATHETIC AFFECTIONS OF THE HEART. 

By sympathetic affections of the heart, I mean those derangements in 
the organ or its functions, which arise either from a primary disease in 
some other organ or part, or else from a general irritable or deranged 
condition of the system, the cardiac derangement being purely sym- 
pathetic. 

Sympathetic affections of the heart often produce symptoms, which to 
the superficial observer might be mistaken for those of organic cardiac 
disease. It is therefore of the highest importance to understand this 
subject. 

It should be remembered that the sympathetic system consists of a 
series of ganglia, extending along each side of the spine, forming a chain 
its whole length, communicating with all the other nerves of the body, 
and sending branches to all the internal organs and viscera. 

The sympathetic generally communicates with the cerebro-spinal nerves 
at their exit from the cranium and vertebral canal, and it sends branches 
to accompany the arteries, often forming communications or plexuses 
around them. " All the internal organs of the head, neck, and trunks 
are thus supplied with branches from the sympathetic, and some of them 
exclusively, hence it is considered the nerve of organic life." 

The sympathetic ganglia appear to be composed of a mixture of me- 
dullary and cineritious matter, and besides tending to equalize nervous 
force may possibly be productive of a peculiar nervous power. 

The sympathetic system probably confers vitality on the organs of 
organic life, and hence exerts a controlling influence over the involuntary 
functions of digestion, absorption, secretion, circulation and nutrition. 
Another important use of the sympathetic system is to form a connec- 



SYMPATHETIC AFFECTIONS OF THE HEART. 507 

tion or communication of one part of the system with another, so that 
one organ or part can take cognizance of the condition of every other 
organ or part, and act accordingly. This provision appears necessary 
so that in case disease seizes, for instance upon the brain, the stomach 
by virtue of its sympathetic relation appreciates the morbid condition of 
the brain, and as food in such a case might add to the cephalic disease, 
the stomach refuses it, and perhaps even throws off that which it had 
already taken. 

Now this sympathy exists as we have seen between all the organs of 
the body, being strongest between those parts which carry on the involun- 
tary functions. But as the cerebro-spinal nerves communicate freely 
wirit the sympathetic, this sympathy exists in a greater or less degree 
between every part of the system, and thus influences more or less every 
voluntary and involuntary function. 

With these considerations it is easy to see that the functions of the 
heart may be materially affected by a local disease of other organs, as 
well as by an irritable or deranged condition of the system generally. 
And so we find that the heart is liable to be excited into vehement and 
tumultuous action by a variety of causes, not immediately connected 
with lesion or disorder of its structure, but depending upon irritation or 
disease located in some remote organ or part of the system. 

The local diseases most liable to produce sympathetic affections of the 
heart, according to my observation, are derangement of the digestive 
organs, of the genital organs, and spinal irritation. And the causes 
most frequently operating, irregular eating, the use of tobacco, and in- 
toxicating drinks, masturbation, onanism, and venereal excesses. 

Symptoms. — The symptoms of sympathetic affections of the heart, 
are similar, in many respects, to those of organic disease; consisting 
often in an increased or diminished action of the heart, by which its 
impulse and sounds become either morbidly increased or diminished ; 
there being generally a corresponding irregularity of the pulse. 

Sometimes, even a slight bellows murmur is heard over the aortic, or 
mitral valves, as well as the anaemic murmur in the jugular veins ; and- 
slight murmurs may sometimes be produced, by compressing the large 
arteries. 

The paroxysm is generally brought on by physical or mental excite- 
ment ; but not always, and when it does occur, from whatever cause, is 
attended with oppression in the prsecordial region, difficult respiration, 
and sometimes syncope or faintness. The irregular cardiac action, is 
also apparently often produced, by an accidental increase of the local 
irritation, or disease of wdiich the cardiac derangement is symptomatic. 
This is true, whether the primary irritation be in the digestive or genital 
organs, or in the spinal cord. 

Diagnosis. — Sympathetic affections of the heart, may generally be 
distinguished from organic disease, by attention to the following differ- 
ences, together with all the symptoms, and circumstances of the case. 

In sympathetic affections of the heart, the paroxysms of palpitation 
generally come on from some physical, or mental excitement, or some 
accidental increase in the local irritation, of which the cardiac affection 
is symptomatic; while in organic disease, the paroxysms more frequent- 



508 DISEASES OF THE CIRCULATORY SYSTEM. 

ly come on, without any very special exciting cause, and frequently, 
while the patient is quiet in bed. 

In sympathetic affections, there is not that lividity of the face, or the 
labial trait, or so constant an intermission of the pulse, as well as dropsi- 
cal tendency, so common in organic cardiac disease. Finally, there is 
seldom heard any distinct murmur in the sympathetic affections, except 
over the aortic or mitral valves, and these are by no means constant or 
frequent ; while in organic disease, there is often a continuous, direct or 
retrograde murmur, or both, in one or more of the valves. 

Causes. — A great variety of causes, may operate to produce sympa- 
thetic affections of the heart. But by far, the most frequent, according 
to my observation, are irregular eating, masturbation, and excessive 
venery ; the use of tobacco, and the excessive use of intoxicating drinks. 

Any derangement of the digestive functions, may produce sympathetic 
cardiac affections ; but I believe that produced by irregular eating, is by 
far the most frequent. And this is not strange, when we remember that 
the stomach, after digesting a meal, is in no condition for taking or 
digesting food, for a few hours at least. But if, as many children, and 
some old people are in the habit of doing, food be taken at irregular 
times, between meals, the food produces an irritation of the stomach, 
and being imperfectly digested, is passed along the intestines in a crude 
state, irritating the intestines. 

This process need only be continued for a little time in order to pro- 
duce derangement of the alimentary canal, and in fact the whole diges- 
tive apparatus. 

Now, as the digestive organs and heart are supplied freely by the 
sympathetic nerves; the heart strongly sympathizes, and hence the 
irregular action of the heart, and all the symptoms which arise in sympa- 
thetic cardiac affections from this cause. 

Over- excitement of the genital organs, by masturbation or sexual ex- 
cesses, is probably the next most frequent cause of sympathetic derange- 
ment of the heart. The habit of masturbation is sometimes commenced 
in both males and females, even during childhood, and if not, at puberty 
or a little later; and during its continuance, the womb in the young 
female, and the testicles in the male become exceedingly irritable, liable 
to be thrown into a state of excitement by the slightest causes. 

Now, as the genital organs are supplied largely by the sympathetic 
and spinal nerves, they readily communicate a morbid impression to the 
stomach and heart, and thus masturbation becomes a frequent cause of 
sympathetic cardiac affections. And besides, masturbation and exces- 
sive venery in the male acts as a direct drain upon the system, weaken- 
ing the blood, and debilitating, enfeebling, and deranging the cerebro- 
spinal and whole nervous system, thus producing or increasing sympa- 
thetic cardiac derangement. 

Tobacco, used by chewing, smoking or snuffing, is a frequent cause of 
sympathetic affections of the heart; and this is not strange when we 
remember that it is a poisonous plant, containing nicotia, nicotianin, and 
an empyreumatic oil, all of which are most virulent poisons, and rapidly 
destructive of animal life. Now, tobacco cannot be brought even in 
smelling distance of living animals without becoming more or less in- 



SYMPATHETIC AFFECTIONS OF THE HEART. 509 

jurious. When, therefore, it is drawn into the nostrils or kept constantly 
in the mouth, undergoing the chewing process, or in the form of smoke, 
is drawn into the lungs, it imparts more or less of its poisonous properties 
to the blood, and also acts as a direct poison to the cerebro-spinal and 
nervous system, deranging, in a greater or less degree, every function of 
the body. In consequence of this derangement of the general system, 
and especially of the cerebro-spinal and nervous system, sympathetic or 
nervous palpitation is produced ; very many marked cases of which have 
fallen under my observation during the past few years. 

Intoxicating liquors are also a frequent cause of sympathetic cardiac 
affections. Alcohol contains no nourishment that can be available in the 
human system, and only appears to act as a tonic by the local and general 
irritability which it produces when taken or administered. The con- 
tinued use of alcohol, then, in any form, produces irritation of the 
mucous membrane of the stomach, and a general irritable condition of 
the system, and thus it leads to nervous palpitation or sympathetic affec- 
tions of the heart. 

Spinal irritation, especially if it be of the cervical portion, whether 
it be the result of direct injury, or symptomatic of other irritations in 
distant parts, may be a cause of nervous palpitation : the irritation 
being communicated by the spinal to the sympathetic nerves, and so to 
the heart itself. 

Various other causes are capable of producing nervous palpitation of 
the heart, such as mental depression, want of sleep, overtaxing the sys- 
tem, fear, anxiety, starvation, or insufficient food, and finally, an anae- 
mic condition from any cause, all of which influences should be taken 
into account, in investigating this multiform variety of cardiac derange- 
ment. 

Prognosis. — The prognosis in sympathetic affections of the heart is 
generally favorable, as the irregular action of the heart usually subsides 
if the local irritation of which it is symptomatic, and its cause, can be 
ascertained and removed. 

Protracted cases may, however, lead on to organic cardiac disease, or 
other derangements. In one case of nervous palpitation that fell under 
my care, in an anaemic female, in which the venous or anaemic murmur 
was very distinct, there was the supervention of turgescence, and finally, 
enlargement of the thyroid gland ; and also exophthalmia or prominence 
of the eyeballs. 

In this case the goitre was increased by any considerable excitement, 
temporarily, and so were the prominence of the eyes ; the increased 
action of the heart, at such times, evidently producing an active conges- 
tion of the thyroid gland, and also of the tissues forming the cushion of 
the eyes, making them more prominent, for the time.* 

Treatment. — In the treatment of nervous palpitation, or sympathetic 
affections of the heart, the remote local irritation should be sought out, 
as well as the cause which has produced it, and both removed if possible. 

If the stomach or digestive organs are the seat of the primary irrita- 
tion, and irregular eating the cause, that habit should at once be cor- 

* The prominence of the eyeballs, though they were not enlarged, gave them that 
appearance, as is usual in such cases, appearing at times almost frightful. 



510 .DISEASES OP THE CIRCULATORY SYSTEM. 

rected, and the patient directed to take food at regular meal hours, and 
nothing between meals. Correcting this habit alone will sometimes 
effect a removal of nervous palpitation. But if the blood has become 
weak, two grains of the citrate of iron may be given in solution, three 
times per day, and continued for a few weeks ; when, as the gastric irri- 
tation subsides, and the anaemic condition is overcome, the sympathetic 
cardiac affection will gradually subside. 

In cases in which the genital organs are the seat of the primary irri- 
tation, and masturbation the cause, whether the patient be male or 
female, it is sometimes difficult to get a confession of the fact. In such 
cases, however, the pale face, the downward look, and the idiotic expres- 
sion of the countenance, together with the " oculo-zygomatic trait," con- 
sisting of a leaden streak extending from the greater angle of the eye 
to the projection of the cheek bone, will generally be sufficient to render 
the diagnosis clear. 

In all cases of this kind, whether the patient be male or female, the 
fearful consequences of the habit should be pointed out, and its continu- 
ance strictly forbidden. If this is obeyed it will generally, in a reason- 
able time, effect a cure of the sympathetic nervous palpitation, and 
health will be restored. 

If, however, the habit has been continued for a considerable time, and 
the blood has become reduced, ten drop doses of the tincture of the chlo- 
ride of iron may be given three times per day, and continued for some 
time. And should there be seminal weakness, or spermatorrhoea, as is 
frequently the case, the muriate of strychnia should be given in z \ of 
a grain doses in solution three times per day, and continued till it is 
overcome. 

In those cases which occur in middle aged males or females, and which 
depend upon onanism, or excessive sexual indulgence, the consequences 
of the imprudence should be pointed out to the patient, and a reform 
insisted upon. And in case this prescription is followed, the nervous 
palpitation will generally subside. 

In those cases depending upon the use of tobacco or intoxicating liquors, 
the habits should be broken off as fast as possible, without producing de- 
lirium tremens, and the cause being removed, the sympathetic cardiac 
affection will generally subside. It is however generally well in these 
cases to administer the syrup of the iodide of iron in ten drop doses 
three times per day for a time, to restore the blood, and correct the 
secretion of the glandular system which is generally more or less impaired 
in such cases. 

In cases of nervous palpitation depending upon spinal irritation, dry 
cups, blisters, or tartar emetic pustulation along the irritated portion of 
the spine, along with such general treatment as maybe indicated, should 
be resorted to. 

Finally, in cases of nervous palpitation depending upon an anaemic 
condition from various causes, a return to the laws of health, and a mild 
tonic course will generally be sufficient to effect a cure. 



NEURALGIA OF THE HEART. 511 

SECTION VII.— NEURALGIA OF THE HEART. 

By neuralgia of the heart, I mean that peculiar neuralgic cardiac af- 
fection, sometimes called angina pectoris, which develops itself by a 
sudden paroxysm of pain in the heart and precordial region, attended in 
some eases with oppression in the chest, dyspnoea and violent palpitations. 

The heart it will be remembered, is supplied with nerves from the 
cardiac plexuses, which are formed by filaments from the pneumogastric 
and sympathetic, all of which communicate freely with the spinal nerves, 
rendering the heart liable to become affected by spinal congestion or 
irritation. 

With this in mind, we are prepared to proceed to the consideration of 
neuralgia of the heart, and first of the symptoms which are developed. 

Symptoms. — An attack generally comes on suddenly with pain in the 
region of the heart, extending in some cases through the left side of the 
chest into the shoulders, and along the nerves of the arm to the fingers. 
Along with the pain there is dyspnoea, anxiety, a sense of suffocation, 
and sometimes distressing palpitation of the heart. 

If an attack occurs while the patient is walking, every motion is at 
once suspended as the least exertion gives rise to intense darting pain 
in the cardiac region. 

During the paroxysm the countenance is pale and expressive of 
anxiety, the extremities are cold, there is turgidity of the vessels of the 
head, and in some cases syncope and convulsions occur. The pulse is 
always irregular, and may be small and feeble, or strong and full, 
during the paroxysm, which lasts from a few minutes to half an hour or 
more. 

The first attacks of this disease occur at long intervals, generally from 
fast walking, over-eating, or violent exercise. But by repetition the 
paroxysms become more violent, occur more frequently, and from very 
slight causes, and are generally of longer duration. After a paroxysm 
has subsided, the patient feels a numbness in the left arm and shoulder ; 
there is slight palpitation and headache, hurried respiration, and an 
anxiety of feeling in the region of the heart. 

Causes. — Various organic lesions of the heart may predispose to this 
disease. But I believe that the exciting causes are similar to those 
which produce gouty, rheumatic and neuralgic affections of other parts. 

It is probable that the disease may arise from irritation in the stomach, 
liver, or almost any other internal organ, by sympathy. But I believe 
it generally occurs from an irritation in the pneumogastric or spinal 
nerves, from cephalic or spinal congestion or irritation. And in a very 
large majority of cases I am confident that spinal congestion or irritation 
is the direct cause of this, as it is of other neuralgic affections. 

Pathology. — Various opinions may be entertained in relation to the 
pathology of this disease. But when we remember the suddenness of the 
attack, the acute and lancinating character of the pain, and that it ex- 
tends from the cervical spine, along the nerves of the arm, as well as to 
the heart, it appears to me there can be no reasonable doubt of its being 
of a purely neuralgic character. 

We have already seen that the sympathetic and pneumogastric nerves 



512 DISEASES OF THE CIRCULATORY SYSTEM. 

which supply the heart, are intimately connected with the cervical por- 
tion of the spinal nerves. Now any sudden congestion, or increased 
irritation of the cervical or superior portion of the spinal cord, may so 
far irritate the brachial and cardiac nerves as to develop this highly acute 
and distressing neuralgic affection. 

The only symptoms attending this disease, not common to neuralgia 
of an intercostal, or any other nerve, are those which arise from the 
derangement in the heart's action ; a circumstance which might be ex- 
pected to arise. 

Prognosis. — The prognosis in cases of this disease not complicated 
with organic lesion of the heart is rather favorable. But the patient 
may die suddenly, from a suspension of the heart's actions, or the 
paroxysms may by repeated repetitions wear out the patient, and thus 
produce death. 

Treatment. — Immediately on an attack of this disease cups should be 
applied to the back of the neck, and along each side of the superior por- 
tion of the spine, and if the patient is plethoric, a few ounces of blood 
should be taken, especially on the left side. 

In weak, ansemic cases no blood should be taken, and should the pulse 
be weak, and the patient appear pale, cold and sinking, the back should 
be rubbed freely, along its whole length, with a warm infusion of capsi- 
cum in vinegar. And should this fail of bringing on speedy reaction, 
warm ginger or pepper tea may be administered, and if necessary warm 
brandy sling. 

Thus the paroxysms may generally be arrested. But in order to pre- 
vent their return, blisters should be applied on each side of the superior 
portion of the spine ; the habits and general health of the patient should 
be corrected, and if the patient is gouty or rheumatic, guaiac, colchicum, 
or iodide of potassium should be given, and continued till the condition 
is overcome as far as may be. 

SECTION VIII.— SYNCOPE. 

By syncope is here meant sudden loss of motion and sensation, with 
diminution or temporary suspension of the action of the heart and of 
respiration. 

Symptoms. — Syncope may come on without any premonitory symptoms, 
but more generally there is slight nausea, oppression at the epigastrium, 
mental confusion and a sinking pulse ; and when it becomes complete, 
the features are pale and sunken, the surface cold, the pulse and respira- 
tion imperceptible, and there is a want of consciousness. The ear 
applied to the region of the heart, however, detects the first sound, 
though it be very weak, and after a little there may be noticed a slight 
inspiration, soon a return of color in the lips, and finally there is a per- 
ceptible pulse at the wrist, with natural respiration and a return of 
consciousness. 

A complete state of syncope seldom lasts more than a few seconds ; 
occasionally, however, it continues several minutes, and in some rare 
cases it is continued for hours or even days. Such are cases of apparent 
death, in all of which there is probably an imperceptible respiratory 



SYNCOPE. 513 

movement and a very feeble action of the heart. I believe, however, 
that the first sound of the heart might generally be detected in such 
cases by careful auscultation. 

Diagnosis. — The conditions with which syncope are liable to be con- 
founded are apnoea and death. In apncea there is a want of conscious- 
ness, absence of sensible respiration, and no perceptible pulse at the 
wrist, and also general venous congestion, with a bloated and livid 
appearance of the face ; while in syncope, though there is the apparent 
suspension of consciousness, respiration, and of the heart's action; the 
countenance is pale and collapsed, and the surface generally bloodless. 
Attention to the cause may also aid in forming a diagnosis if it be remem- 
bered that the causes of apncea act directly to suspend respiration, while 
the causes of syncope act more directly upon the heart. 

In cases of syncope that resemble death, there is a want of coldness 
of the body, of the cadaveric rigidity, and also of the settling of the 
blood to dependent parts ; but generally a possibility of detecting, by 
careful auscultation, the first sound of the heart; all of which are indica- 
tions of remaining vitality. In cases of doubt, however, burial should 
be deferred till there is a commencement of putrefaction, lest the unfor- 
tunate blunder of burying alive be fallen into. 

In cases of hysterical insensibility, in which the patient lies for days 
without consciousness ; there is a gentle respiratory movement and a dis- 
tinct pulse at the wrist, which afford sufficient evidence of remaining 
vitality. 

Causes. — The causes of syncope may act directly upon the heart, such 
as the effects of organic disease, of neuralgia of the heart, rheumatism 
or gout, the effects of certain poisons, air in the blood vessels, &c. Or 
they may act on the heart through the nervous system. A great variety 
of causes act to produce syncope in this way, such as terror, sudden 
fright, severe pain, violent injuries, hunger, &c. 

Loss of blood or a weak state of the blood is also a frequent cause of 
syncope. This cause, probably, operates by depriving the brain of a 
due amount of stimulus, thus suspending, for the time, the heart's 
action. In fact it can scarcely be otherwise, for it is well known that 
syncope occurs more frequently when the patient is in the sitting pos- 
ture, while less blood is passing to the brain, than when in the hori- 
zontal position. 

Prognosis. — The prognosis in syncope is generally favorable, unless 
it be attended with great loss of blood, or organic disease of the heart. 
I believe, however, that fatal syncope sometimes occurs in acute disease 
in which there is great debility, from a little imprudent exertion ; an 
unfortunate case of which very recently fell under my observatation. 

Treatment. — In all cases of approaching or complete syncope the 
patient should lie down, or be placed in the horizontal position, that 
more blood may flow to the brain, and thus sufficient nervous influence 
be generated and sent to the heart, to enable it to resume its functions. 

After placing the patient in the horizontal position, cold water should 
be sprinkled in the face, to arouse the nervous system, and if this fails, 
camphor, spirits of ammonia, or other pungent volatile liquids should be 
held to the nose for the same purpose. If the patient does not readily 



514 DISEASES OF THE CIRCULATORY SYSTEM. 

revive, and is able to swallow, half a drachm of the tincture of camphor, 
or of the aromatic spirit of ammonia, may be administered, in a little 
water, and should this be insufficient, brandy and water may be required. 
Should the patient be unable to swallow, brandy or carbonate of am- 
monia, diluted with mucilage of gum arabic, should be injected into the 
rectum. Sinapisms should be applied to the epigastrium, an infusion of 
capsicum along the spine, frictions of flannel should be made to the ex- 
tremities, and finally, if the case is obstinate, artificial respiration should 
be resorted to, as for cases of asphyxia. 

SECTION IX.— ARTERITIS. 

By arteritis, I mean inflammation of the arteries, which, though an 
occasional, is not a very frequent occurrence. 

The arteries, it will be remembered, are cylindrical tubes, which con- 
vey the blood from the ventricles of the heart to every part of the sys- 
tem. The aorta proceeding from the left ventricle, and conveying the 
arterial blood to the capillaries, throughout the system ; the pulmonary 
artery conveying the venous blood from the right ventricle to the capil- 
laries of the lungs. 

The branches of the aorta are given off mostly at right angles ; while 
in the limbs, the branches from the main arteries, are given off at an 
acute angle, in the one case, tending to check the impetus of the blood 
from the main trunk, and in the other, to favor it. The onward flow of 
the blood in the arteries, is also favored by the increased capacity of the 
branches, towards their extremities, every division of the arteries giving 
a combined area of the two branches, greater than that of the original 
trunk, before division. 

The arteries communicate freely with each other, and finally terminate 
in the capillaries, only about 7 oVo of an inch in diameter, which extend 
from the extreme arteries, to the extreme veins, and form a network 
through every part of the body. 

The arteries, as they are distributed through the body, are included 
in an areolar investment, or sheath ; being themselves composed of three 
coats, an external areolo-fibrous, a middle coat of yellow elastic tissue, 
and muscular fibres, and an internal serous membrane, continuous with 
that which lines the heart, and through the capillaries, with the lining 
membrane of the veins. 

The coats of the arteries are supplied with vessels, the vasa vasorum ; 
and they are also supplied with nerves, like other parts of the system ; 
but the mode of distribution of the nerves, is not very clear. 

The arteries, thus constituted, are liable to become inflamed, the symp- 
toms of which we are now prepared to consider. 

Symptoms. — Slight inflammation of the arteries may exist, without 
any very decided symptoms. But marked cases of arteritis are at- 
tended with heat, pain, tenderness, and throbbing, and if it is sufficient 
to produce a roughness of the lining membrane, there may be a rustling 
sound produced, discoverable by auscultation. If the larger arterial 
trunks are involved in the inflammation, the heart suffers sympathetically, 
and along with a feeling of faintness, anxiety, and restlessness, there is 



ARTERITIS. 6l5 

more or less febrile excitement. And in cases, in which the aorta is in- 
flamed, there is generally, in addition to the symptoms already enumer- 
ated, more or less oppression of breathing. 

In inflammation of the arteries of the extremities, the vessels sometimes 
become obstructed, either by the thickening of the arterial coats; by the 
exudation of fibrin into the cavity, or its deposition from the blood, or 
else from actual coagulation of the blood. 

In cases of obstruction in the arteries, from either cause, the pulsation 
ceases ; the artery may be felt like a cord along the limb, and in some 
cases, the limb or part supplied by the obstructed artery, on the suspen- 
sion of its functions, becomes numb, paralyzed, and even mortified.^. 

Partial obstruction of the pulmonary arteries may exist, and yet a 
tolerable degree of health be enjoyed ; but in case the obstruction becomes 
complete, immediate death is inevitable. In advanced stages of severe 
arteritis, the fever may assume a typhoid character, in consequence of 
contamination of the blood, by the lymph, pus, &c; products of the in- 
flammation. 

Such, I believe, are the usual symptoms of arteritis. And if it be 
found in some cases, that the symptoms are not very indicative, they may 
be inferred to arise from arteritis, if they are not such as are known to 
arise from any other disease. 

Anatomical Characters. — The inner surface of the artery, as far as 
the inflammation has extended, is red and more or less roughened ; the 
coats are thickened, and perhaps softened, and readily separable ; the 
vasa vasorum are injected, and lymph or pus may be found on the inner 
surface, or between the coats. Coagulated blood is often found lining 
the vessels, or filling their cavities, and sometimes ulceration is discovered 
along the inner surface of the vessel. 

In chronic cases, there is left, besides, the redness, thickening and 
softening. In the acute form of the disease various organic changes are 
found in the coats of the vessels, and sometimes morbid deposits, consti- 
tuting organic diseases of the arteries, in many respects similar to those 
of the heart, the result of cardiac inflammation. 

Causes. — Various causes may operate to produce arteritis ; among the 
most frequent of which are direct injuries, such as the wounding or 
tying of arteries, extension of inflammation from inflamed or suppurat- 
ing parts, and sudden exposure to cold. It may also arise from the me- 
tastasis of gout, rheumatism, &c, from repelled cutaneous eruptions, 
from the use of tobacco and intoxicating liquors ; and, finally, in its 
chronic form, from the irritation produced by the presence of calcareous, 
steatomatous, tuberculous, or other deposits, which we have already seen 
are liable to take place in the coats of the arteries. 

Treatment. — In moderate cases of arteritis, rest, low diet, saline 
cathartics, leeches, and perhaps blisters, may be sufficient to arrest the 
disease. But violent cases, occurring in robust subjects, may require 
general bleeding, rest in the horizontal position, saline cathartics, and 
antimonials ; leeches, fomentations and blisters along the inflamed ves- 
sels, and, if the disease is obstinate, a slight mercurial course. 

In cases depending upon gout or rheumatism, in addition to the other 
measures that may be indicated, nitre, colchicum, or iodide of potassium 



516 DISEASES OF THE CIRCULATORY SYSTEM. 

should be given and continued for a reasonable time. Finally, in all 
cases of arteritis in which gangrene occurs, quinine, camphor, wine- whey, 
broths, &c, must be resorted to, till the system permanently rallies from 
its depressing effects. 

SECTION X.— PHLEBITIS. 

By phlebitis, from $fc*4, "a vein," and the termination itis, I mean in- 
flammation of the veins. 

The veins commence by minute radicles in the capillaries, which extend 
from the extreme arteries, in every part of the system ; and converge, 
forming larger branches, till they constitute the main trunks which con- 
vey the venous blood directly to the heart. 

The veins of the systemic circulation convey the venous blood from 
the capillaries to the right auricle of the heart, while the pulmonary 
veins convey the arterial blood from the capillaries of the lungs to the 
left auricle. 

The veins are much thinner in structure than the arteries, but they 
have three coats, an external, firm and strong, resembling that of the 
arteries ; a middle coat with an external layer of circular fibrous tissue, 
and an inner layer of longitudinal muscular fibres, and finally an in- 
ternal serous coat, continuous with the lining membrane of the heart, 
and through the capillaries with that of the arteries. 

The veins are furnished with valves, and like the arteries are supplied 
with nutritious vessels, and it is probable that nervous filaments are dis- 
tributed to their coats. The veins then have a structure very similar to 
the arteries, though their coats are thinner, and they have not the 
elastic coat of the arteries. The deep veins that accompany the arte- 
ries, are, in the limbs, generally included in the same sheath with them. 
The veins thus situated and constituted are liable to become inflamed 
from various causes, the symptoms of which we will now proceed to con- 
sider. 

Symptoms. — Inflammation of the veins are attended with pain, tender- 
ness, and swelling along the course of the affected vessels, and in the 
adjoining tissues. The inflamed vessels may often be felt like firm 
cords, unless, as sometimes happens, the limb becomes greatly distended 
by effusion from obstruction to the returning blood, as well as from an 
extension of the inflammation to the adjoining tissues. 

If the veins involved be small, the obstruction caused by matter 
thrown out on their inner surface, and by the coagulated blood, may lead 
to no very serious results. But if the large internal veins are thus 
obstructed the worst consequences may follow. 

In case the inflammation subsides, there may be a solution of the coa- 
gulum, and thus the circulation through the vessels be restored. But if 
suppuration takes place, the matter may be confined to the inflamed 
part by coagulated blood, producing abscesses along the veins. Or the 
pus may be carried along by the current of blood if the inflamed vessels 
remain pervious, and the most serious constitutional disturbance follow. 

In some cases of phlebitis, in depraved constitutions, pus enters the 
circulation freely from the inner surface of the inflamed veins leading 



PHLEBITIS. 517 

to purulent depositions and abscesses in different parts of the system, 
and finally to emaciation, exhaustion and death. 

Ordinary cases of phlebitis commence with a chill, or chills, which are 
followed by more or less febrile excitement. But in case considerable 
pus enters the circulation, the pulse becomes frequent and feeble, the 
extremities cold, the respiration difficult, the countenance sunken, the 
tongue dry, and finally to complete the typhoid train of symptoms, there 
is restlessness, delirium, and generally a fatal termination. 

Diagnosis. — The pain, swelling, tenderness, and other symptoms enu- 
merated, are generally sufficient to distinguish phlebitis in the extremi- 
ties. And in cases in which the large internal veins are the seat of the 
inflammation, the disease may generally be diagnosticated by the swelled 
and dark appearance of the veins, upon the surface, which carry blood 
into the affected trunk. It may, however, be difficult, or impossible in 
some cases, to distinguish phlebitis involving the portal veins. But the 
epigastric pain, and tenderness, the slight tympanitis, the congested or 
full appearance of the superficial veins, the chills and febrile reaction, 
and finally the congested condition of the liver, spleen and other abdo- 
minal viscera, together with the typhoid symptoms, when they supervene, 
may serve to render the diagnosis probable at least. 

Phlebitis of the pulmonary veins may be distinguished with tolerable 
certainty by the pain, dyspnoea, and congestion of the lungs, the livi- 
dity and irregular action of the heart, together with the other symptoms 
enumerated as common to phlebitis. 

Anatomical Characters. — On post-mortem examination, the coats of the 
veins are found either contracted, thickened, softened or indurated. 
Coagulable lymph or coagulated blood are found adhering to the inner 
surface of the vessels, or completely filling them, and portions of the 
inflamed vessels often contain pus, or the vessels may be found oblite- 
rated along the track of the inflammation. The adjoining tissues are 
generally found infiltrated with pus, or to have contracted adhesions 
from an extension of the inflammation to these parts. 

If the pulmonary veins have been the seat of the inflammation, in ad- 
dition to the ordinary appearances, the lung may be found congested, or 
gorged with blood. And in cases in which the portal veins have been 
involved, in addition to the appearances already described as attending 
phlebitis, abscesses may be found in the liver and other abdominal viscera, 
and the peritoneum may show signs of congestion or inflammation. 

Causes. — A feeble and depraved condition of the system, strongly pre- 
disposes to phlebitis. And it is probable that certain atmospheric in- 
fluences of a pernicious character tend to produce the disease. Phlebitis 
generally however arises from direct injury of the veins, such as from 
venesection, if performed with a dull or contaminated lancet, from the 
operation for varicose veins, amputations, or any accidental wound of 
the veins. 

The disease is very apt to occur in the puerperal state, the inflamma- 
tion commencing in the uterine veins, and extending to the spermatic, 
hypogastric, iliac, and femoral veins, and sometimes even to the vena 
cava. It is probable also that phlebitis may arise from sudden exposure 
to cold, and perhaps from the translation of rheumatism, gout, &c. 



518 DISEASES OF THE CIRCULATORY SYSTEM. 

Phlebitis when once established tends to pass from the smaller to the 
larger veins, the inflammation being extended along the coats of the 
veins, or else being in part communicated along the trunks by the pas- 
sage of acrid matter, products of the inflammation. 

Prognosis. — From the depraved constitutions in which phlebitis oc- 
curs, and also the tendency to pass to the larger venous trunks, as well 
as the danger of their obstruction, and of the formation of abscesses in 
different parts of the system, phlebitis should always be regarded with a 
due degree of solicitude. 

Treatment. — In cases of active phlebitis, saline cathartics, low diet, 
antimonials, anodynes, leeches and cold applications along the inflamed 
part, and if necessary mercurials are the remedies upon which our main 
reliance is to be placed. But in cases of passive phlebitis, a moderately 
nourishing diet, mild laxatives, a few leeches, and warm fomentations of 
hops to the inflamed part will do best, and if sinking comes on, quinine, 
wine-whey, &c, will generally be indicated. In cases in which the parts 
remain swelled or indurated after the inflammation subsides, blisters or 
the application of iodine or mercurial ointments may be required. 

SECTION XL— CRURAL PHLEBITIS. 

By crural phlebitis, I mean that variety which generally occurs in the 
puerperal state, commencing in the uterine veins, and extending to the 
iliac, and generally to the large veins of the affected limb, constituting 
what has been called phlegmasia dolens, milk-leg, &c. 

This form of phlebitis is not confined exclusively to the puerperal 
state, but more generally occurs in that condition, being developed gene- 
rally within the first ten days after confinement. 

Symptoms. — There is generally at first a chill, with pain and some 
stiffness in the groin of one side. Soon there is a greater or less degree 
of febrile reaction, attended with swelling in the groin, which rapidly 
extends itself along the whole limb, till it becomes distended, and ex- 
quisitely tender. 

To the sight the swelling may exhibit an even and uniform appearance. 
But if the hand be passed over the limb, the veins may be felt in hard 
ridges like cords under the skin. More or less pain is generally felt in 
the iliac region of the affected side, probably in consequence of the in- 
flammation which has extended from the uterine along these veins to the 
crural. Considerable fever may attend this disease, and the patient is 
apt to be quite restless. 

The inflammation may sometimes be arrested very soon, if attended 
to at once, but if neglected, it may continue for ten or fifteen days, and 
in some cases for several weeks. When it is about terminating by re- 
solution, the surface of the body becomes moist, the urine deposits a red- 
dish sediment and the fever gradually abates. 

The declension of the swelling is always very gradual, if it has con- 
tinued for any considerable time, in consequence of the structural changes 
which have taken place in the vessels that have been involved. And 
there may remain a degree of stiffness of the limb for a long time, even 
after the swelling has nearly or quite subsided. 



CRURAL PHLEBITIS. 519 

In some cases suppuration takes place and abscesses are formed, or the 
pus passes into the circulation, leading to the formation of abscesses in 
various parts of the body, or else to a general contamination of the sys- 
tem, a long train of typhoid symptoms ; and finally to a fatal termina- 
tion. 

Anatomical Characters. — On post-mortem examination the uterine 
veins of the side to which the placenta had been attached, show marks 
of having been inflamed, being impervious as well as the common and in- 
ternal iliacs of the same side. Sometimes these veins are found con- 
tracted down to a cord-like substance, their cavities being obliterated, 
and at other points, or in other cases, they are found plugged up by firm 
coagula. The veins of the limb are found with their coats thickened, or 
they are contracted and filled up with dark coagula. 

Causes. — There is probably a strong predisposition to this disease in 
some constitutions arising from a depraved condition of the system. And 
the disease may also be favored by certain epidemic or endemic influ- 
ences. 

But the direct cause of crural phlebitis occurring in the puerperal 
state is probably the exposure of the uterine veins to atmospheric air 
caused by the separation of the placenta. This appears the more pro- 
bable when we remember that phlebitis is often produced by an exposure 
of the veins in amputations, wounds, &c. It has also appeared to me 
that crural phlebitis may be produced in some cases, by injuries which 
the iliac or other veins receive during parturition, but this is not quite 
certain. 

Treatment. — In cases of this disease, in which the inflammation is of 
an active character, general bleeding may occasionally be required, but 
never in cases in which the inflammation is of a passive character, as is 
too often the case. 

Cups, wet or dry, however, should always be applied along the lumbar 
and sacral regions on the affected side, and leeches above Poupart's liga- 
ment, and along the crural veins. Ten grains of calomel or three blue 
pills should be given at once, and followed, if necessary, in six hours by 
half an ounce of the sulphate of magnesia to produce tolerable free 
catharsis. After the operation of the cathartic, if the patient is robust, 
and the inflammation active, four grains each of James's and Dover's 
powder may be given every six hours till the pain and febrile excitement 
subside. But in debilitated cases, in which the inflammation is of a 
passive character, two grains of the sulphate of quinine should be given 
with the Dover's instead of the antimonial powder. 

In active cases, in which there is considerable heat in the limb, after 
leeching it should be kept cool and bathed with a solution made by dis- 
solving two drachms of muriate of ammonia in four ounces each of vine- 
gar and water, to which two drachms of laudanum may be added. But 
in debilitated cases, in which there is considerable swelling, with little 
or no heat, the above solution may be applied, warm, every six hours, 
with the addition of two ounces of tincture of camphor instead of the 
laudanum, and the limb kept covered with hops wet in warm vinegar. 



520 DISEASES OF THE CIRCULATORY SYSTEM. 



SECTION XII.— HEMORRHAGE. 

By hemorrhage is here meant an escape of blood from vessels through 
which it circulates in a state of health. But as traumatic hemorrhage 
belongs rather to the surgeon, I design to consider more especially here 
spontaneous hemorrhage, or that which arises from causes acting through 
the organization. 

Spontaneous hemorrhage may take place from the arteries, veins or 
capillaries, but it is generally from the capillaries, and it may depend 
upon a diseased state of the vessels, of the blood, or of both ; with or 
without derangement of the circulation. Or hemorrhage may occur 
from derangement of the circulation, probably without any previous dis- 
ease of the arteries, veins or capillaries. 

While spontaneous hemorrhage, as we have seen, may take place from 
the arteries or veins, it is in a large majority of cases directly from the 
capillary vessels that the blood escapes. And in order to understand 
this subject it is proper to call to mind the anatomy, physiology, and 
functions of these vessels. 

The capillaries, it will be remembered, extend from the extreme 
arteries to the extreme veins, being about gVth of an inch in length, and 
3- Voth of an inch in diameter, and they thus constitute a microscopic 
network through every part of the body. They are quite uniform in 
size, inosculating on the one hand with the terminal arteries, and on the 
other with the minute veins, and have among themselves frequent 
divisions and communications. 

The capillaries thus constituted and situated, serve not only to convey 
the blood from the extreme arteries to the extreme veins, but they supply 
by exudation through their thin walls, matter to nourish the interstitial 
tissues, and also absorb various soluble matters which are presented to 
them. It is, then, through these minute and delicate vessels, which 
everywhere pervade the organs and tissues of the body, that the blood 
generally escapes in cases of spontaneous hemorrhage, which is now about 
to engage our attention. 

Now, hemorrhage may occur from directly opposite conditions of the 
system; in the one case, the vital forces being above the standard of 
health, and in the other, below; constituting, as in inflammation, one 
grand division into active and passive. 

Active hemorrhage occurs in strong and vigorous constitutions, in which 
the circulation is active, with a strong full pulse, and in consequence 
generally, as I believe, of a hereditary, or accidental irritability, or weak- 
ness of the capillaries of the whole system; or of those of the organ or 
tissue, from which the hemorrhage occurs. 

Passive hemorrhage, on the other hand, occurs in weak and debilitated 
constitutions, in which the blood is weak or watery; the circulation lan- 
guid; the pulse feeble, and the extremities cold, and in consequence 
probably of the watery state of the blood, and the relaxed condition of 
the capillaries, together with the local congestion, so common in such 
cases. 

There are various symptoms, common to both active and passive hemor- 



HEMORRHAGE. 521 

rhagc, as well as some, which are peculiar to each, which we will now 
proceed to consider. 

Symptoms, — I believe there is generally a sense of heat, and some- 
times of pain, or fullness in parts, from which hemorrhage is about to 
take place. 

When the hemorrhage occurs, if it be considerable, the local heat, 
pain or feeling of congestion, will subside, and there may be a sinking 
of the pulse, and perhaps faintness or syncope, with more or less general 
nervous irritability. In case the hemorrhage is internal, the above 
symptoms, together with the evidences afforded by palpation, auscultation, 
percussion, &c, will generally be sufficient to render the diagnosis tolera- 
bly clear at least. 

In active hemorrhage, the blood is of a bright-red color, and readily 
coagulates, forming a large soft clot; and this is not strange, when we 
remember that it comes from robust and vigorous constitutions, or florid 
individuals, with a strong appetite, and active digestive powers. 

In passive hemorrhage, however, the blood is of a darkish color, and 
but slightly, if at all coagulable; and not unfrequently in such cases, 
blood is extravasated beneath the skin, forming ecchymosis. If the 
hemorrhage is considerable, the pulse becomes weak ; the face pale ; the 
extremities cold, and unless it be arrested, there may be cold sweats, 
syncope, convulsions, and finally a fatal termination. 

Hemorrhage, whether active or passive, is very apt to return, as often 
as the causes or circumstances which produced it recur, or are repeated ; 
whether it be daily, weekly, monthly, yearly, or at irregular periods. 

Active hemorrhage may be borne, if not too copious, even though it be 
repeated occasionally; as the blood is strong, and will bear the dilution 
which takes place, from the absorption of fluids, after any considerable 
loss of blood. And it is possible that the system becomes habituated to 
active hemorrhage, in some cases, so that nearly sufficient blood is pro- 
duced to keep up the integrity of the system, notwithstanding the loss 
which occurs. 

Passive hemorrhage, however, being the result of debility, and an 
imperfect circulation, is but illy borne. And if continued or repeated, 
is liable to lead to the most serious consequences. 

Causes. — I believe there is in many cases a hereditary predisposition 
to hemorrhage, consisting in a weak, relaxed, or irritable condition of 
the capillaries of the whole system, or of those in the particular part 
from which the hemorrhage occurs. Age, too, appears to have an influ- 
ence in favoring particular varieties of hemorrhage ; epistaxis being 
most frequent during childhood ; hsemoptisis between fifteen and thirty ; 
while hsematruia is very liable to occur in advanced age. 

Active hemorrhage may be caused however, in those who are predis- 
posed, by every influence which tends to produce a full plethoric condi- 
tion, in which the vital force is above the standard of health, such as an 
excess of animal food, overeating, want of exercise, &c, while the pas- 
sive variety may be produced by any influence which depresses vitality 
below the standard of health, such as starvation, unwholesome food, im- 
pure air, and other kindred influences. 

Finally, besides these general influences, various local causes may ope- 
rate to produce either variety, such as irritations, injuries, wounds, &c. 



522 DISEASES OF THE CIRCULATORY SYSTEM. 

Prognosis. — The prognosis in active hemorrhage is favorable, unless 
it be very copious or frequently repeated, in which case it may lead to 
fearful or even fatal results. 

In passive hemorrhage, if copious or frequently repeated, the prognosis 
is always unfavorable, from the great debility which it produces, and the 
liability there always is of sudden and fatal prostration. 

Treatment — The first consideration on examining a patient with 
hemorrhage is, whether the loss of blood may not be salutary, as it is 
in certain morbid conditions of the system, with general or local de- 
rangement. 

If then it be found on examination that the loss of blood is a less 
calamity than the morbid condition it is relieving, the hemorrhage should 
be permitted to go on till it ceases to be salutary, at which time proper 
remedies should be resorted to for its arrest. 

In all cases of hemorrhage in which an arrest of the flow is desirable, 
the exact deviation of the system from the standard of health should be 
taken, and thus the active or passive character of the hemorrhage be 
ascertained. When this is done, the indications of treatment are gene- 
rally clear. 

The indications, if the hemorrhage be active, are to diminish the 
activity of the circulation, to lessen irritation in, and determination of 
blood to the part from which the hemorrhage occurs, to constringe the 
capillaries of the part, and finally, to correct the habits and conditions 
of the patient which produced, and would be likely to lead to a return 
of it. 

The activity of the circulation may be lessened by bleeding, saline 
cathartics, and sedatives ; as digitalis, nitre, &c. Irritation in, and de- 
termination of blood to the part may be lessened by cold applications to 
the seat of the hemorrhage, and warmth, sinapisms, or blisters to remote 
parts. To constringe the capillaries, astringents, such as tannin, alum, 
&c, should be administered internally, and, if convenient, applied to 
the seat of the hemorrhage. 

Having arrested the flow of blood, the habits of the patient should be 
inquired into and corrected. The patient should be placed on a plain 
and not overstimulating diet, should be required to eat moderately, and 
take a reasonable amount of exercise, and should avoid every cause that 
might tend to favor a return of the hemorrhage. 

The indications in passive hemorrhage are to equalize the circulation, 
to constringe the relaxed capillary vessels, to restore to a healthy condi- 
tion the weakened blood and the general powers of the system ; and, 
finally to correct the habits of the patient, upon which this weak and de- 
bilitated condition of the system depends. 

To equalize the circulation, stimulants if necessary ; stimulating fric- 
tions along the spine, the warm foot-bath, or sinapisms to the extremi- 
ties ; and, finally, blisters will generally do best. 

To constringe the relaxed capillaries, astringents, such as alum, tan- 
nin, geranium, &c, will generally do best. And to restore the blood 
and general powers of the system, the tonic bitters, iron, and especially 
the tincture of the chloride, with a generous diet may be required. And, 
finally, all the habits of the patient should be corrected, which might 

nd to favor a return of the hemorrhage. 



EPISTAXIS. 523 

SECTION XIII.— EPISTAXIS. 

By epistaxis, from e**, "upon," and otafa, "I flow drop by drop," is 
here meant bleeding from the nose, whether active or passive ; the blood 
proceeding from the capillaries of the Schneiderian membrane. 

Epistaxis is probably by far the most frequent variety of hemorrhage, 
and occurs often in early life, in part perhaps from the large size of the 
head in comparison with the rest of the body ; and also in part from the 
habit of pricking the nose, &c, so common among children. 

Symptoms. — Bleeding at the nose is generally preceded by symptoms 
indicative of cephalic congestion, such as a sense of weight in the temples, 
pain in the head, perhaps throbbing of the carotids, a flushed face, gid- 
diness, ringing in the ears, and a sense of tickling, or stinging pain in 
the nose. And in weak, debilitated and irritable persons, the flow may 
be preceded by cold extremities, chills, a shrunken state of the skin, and 
a small corded and quick pulse. 

The flow of blood is generally attended with a relief of the cephalic 
symptoms, especially in active cases. The blood generally drops from 
the nose, but it may pass, or a portion of it at least, along the posterior 
nares to the fauces, and be discharged from the mouth. Generally but 
a few ounces of blood is lost, but sometimes the flow is profuse and pro- 
tracted, requiring active or persevering measures for its suppression. 

Causes. — Whatever produces a preternatural determination of blood 
to the head, or Schneiderian membrane of the nose, may give rise to epis- 
taxis, such as sneezing, stooping, mental excitement, intestinal irrita- 
tion, &c. 

Epistaxis may also occur from organic diseases of the heart, from 
suppression of the hemorrhoidal or menstrual discharge, and it is apt to 
occur in dropsical patients, in consequence of the watery state of the 
blood and a passive cephalic tendency. 

Prognosis. — Active hemorrhage from the nose is not usually attended 
with any considerable danger, unless it is very profuse and frequently 
repeated. But in passive cases it is often exceedingly troublesome, and 
sometimes attended with considerable danger, in consequence of the 
great prostration which it produces. Epistaxis, however, very rarely 
terminates fatally from direct loss of blood. 

Treatment. — The treatment of epistaxis of course depends upon the 
nature of the hemorrhage and the general condition of the patient. If 
the hemorrhage is active, and a consequence of the suppression of some 
natural or habitual discharge, no measures should be taken to arrest it, 
unless the loss of blood is very considerable. 

If, however, the bleeding continues beyond the point at which it 
ceases to be salutary, and in all cases of passive epistaxis immediate 
measures should be taken to arrest the bleeding as soon as possible. 

The feet should be placed in warm water, and then sinapisms applied 
to the feet or limbs. Cold applications should be made to the back of 
the neck and nose, and if necessary to the groins, the patient being 
placed in the sitting posture. 

If, however, the bleeding still continues, ipecac should be given in 
one-fourth of a grain doses, every fifteen minutes, till the hemorrhage is 



524 DISEASES OF THE CIRCULATORY SYSTEM. 

arrested or slight nausea is produced. If this too should fail, full doses 
of alum or tannin should be given every two or three hours, and a satu- 
rated solution of alum snuffed or injected into the nose. If still obsti- 
nate, pressure should be made on the bleeding nostril, and the arm of 
the bleeding side raised perpendicularly upwards and retained there a 
short time, the patient being in a standing posture, as suggested by Dr. 
Negrier. 

Finally, if all these measures fail, a piece of sponge cut to fit the 
nostril may be saturated with a solution of alum or tannin, and having a 
string made fast to it, should be passed carefully up the nostril of the 
bleeding side, and if it arrests the bleeding, it should be left for three or 
four days, but if not, it should be withdrawn, and the anterior and pos- 
terior nares closed with small rolls of linen cloth. This last measure is, 
however, attended with considerable difficulty, and I believe need rarely 
be resorted to, if the other remedies be faithfully applied. 

To prevent a return of epistaxis, the habits of the patient, as well as 
the condition of the system upon which it depends should be corrected, 
and if the hemorrhage is of a passive character the tincture of the chlo- 
ride of iron, continued for a time, is a valuable remedy to prevent its 
return. 

SECTION XIV.— ILEMATEMESIS. 

By hsematemesis, from cu^a, "blood," and e^cw, "I vomit," is here 
meant the vomiting of blood, which has accumulated in the stomach from 
gastric hemorrhage. 

I desire also to include, under this head, all cases of gastric hemor- 
rhage, whether the blood be vomited or passed along into the intestines, 
as is sometimes the case. 

Gastric hemorrhage may take place from the arteries or veins, but the 
blood generally escapes, as in other cases of spontaneous hemorrhage, 
directly from the capillaries of the mucous membrane. 

Symptoms. — The premonitory symptoms of hemorrhage from the 
stomach, are a sense of weight, fullness, heat, and pressure in the epi- 
gastrium, an irregular appetite, pain in the hypochondrium, faintness, 
nausea ; a small and irregular pulse, palpitation, cold extremities, a pale 
countenance, and anxiety, weakness, and constriction about the breast. 

After these symptoms have continued for a time, there is a feeling of 
approaching syncope, with distressing nausea, and finally, in most cases, 
copious ejections of blood from the stomach. In some cases, however, 
vomiting is not provoked, the blood passing along into the intestines, as 
I have already suggested. 

The blood ejected by vomiting, is sometimes in a liquid state, and of 
a bright-red color. More generally, however, the blood is coagulated, 
and of a darkish color; sometimes being almost black. The quantity 
of blood thrown off, is sometimes considerable ; in two cases that fell 
under my care, I think it must have exceeded two quarts from each. In 
some cases, however, it is much less than that. 

Sometimes partial syncope follows the ejection of blood, and there 
may be pain in the epigastric and abdominal regions. But generally, I 



IliEMATEMESIS. 525 

believe, the patient, though exhausted, feels relieved for a time after the 
vomiting. The relief may, however, be transient; for not unfrequently 
the same train of symptoms recur in a few hours, and more blood is 
ejected by vomiting. And this may be repeated several times, unless 
the hemorrhage be arrested. 

It is probable that a portion of the blood in gastric hemorrhage, always 
passes into the intestines, and hence the dark alvine discharges which 
occur, for several days, after an attack of haematemesis. 

Diagnosis. — Haematemesis may be distinguished by careful attention 
to all the symptoms, and by ascertaining with certainty, that no hemor- 
rhage has occurred from the nostrils or fauces, and the blood swallowed, 
and that the ejected blood was not thrown up by coughing, as it would 
be, if it came from the lungs. In cases of gastric hemorrhage, in which 
no vomiting occurs ; the sense of fullness, heat, pain, &c, together with 
faintness, and distension of the stomach, and all the other symptoms, 
which attend this affection, may render the diagnosis probable, at least. 

Causes. — Any thing which interrupts the portal circulation, such as 
hepatic, congestion, &c, may produce this variety of hemorrhage. Or 
it may occur from suppression of the menstrual or hemorrhoidal discharge, 
as well as from the final suppression or cessation of the menses, at the 
critical period of life. 

It may also occur from any cause, external or internal, capable of 
producing congestion, irritation, inflammation or ulceration of the gastric 
mucous membrane, such as blows on the epigastrium, acrid substances 
swallowed, alcoholic liquors, gluttony, fits of anger, &c. Or the passive 
variety may occur from any cause, capable of depressing vitality, or that 
produces a w T eak state of the blood, and a relaxed condition of the capil- 
laries of the gastric mucous membrane, such as insufficient or unwhole- 
some food, filth, and impure air; the use of tobacco, excessive venery, 
and various other depressing influences. Finally, hgematemesis may be 
produced by ulceration, cancer, and other organic diseases of the stomach, 
as well as by diseases of the liver and spleen, and various other internal 
organic affections. 

Anatomical Characters. — In some cases the gastric mucous membrane 
appears nearly natural, but generally it shows signs of congestion or in- 
flammation, being red, sometimes softened, or covered with dark spots, 
or else ulcerated. If the hemorrhage has proceeded from an accidental 
wound of a vessel it may often be discovered ; and if it has been the 
result of any organic disease, the lesion, of course, will be presented. 

Prognosis. — The prognosis in hsematemesis, arising from causes that 
admit of removal, is not very unfavorable, unless it be copious, or fre- 
quently repeated. But in passive cases, and in all such as depend upon 
organic disease of the stomach, or other abdominal viscera, the prognosis 
is unfavorable. Death may occur suddenly from gastric hemorrhage, 
without the ejection, by vomiting, of any blood. 

Treatment. — The treatment proper for haematemesis depends entirely 
upon the general condition of the patient. If robust and strong, with a 
full and active pulse, general bleeding may sometimes be indicated ; but 
not generally, I think. Leeches or cups over the stomach may, how- 
ever, be of service in such cases. 



526 DISEASES OP THE CIRCULATORY SYSTEM. 

After bleeding, leeching, or cupping, if indicated, the warm foot-bath 
should be resorted to, and sinapisms applied to the epigastrium and 
extremities. Ipecac, in one-fourth grain doses, should be given, every 
fifteen minutes, till the hemorrhage is arrested, or slight nausea is pro- 
duced. The bowels should be moved by an injection or mild cathartic, 
if necessary ; and, if the bleeding continues, the patient should be kept 
quiet, and two grains of tannin administered every two hours, and con- 
tinued till it produces its astringent effect upon the gastric mucous 
membrane. 

After arresting the hemorrhage ; if it has been passive, and the patient 
is anaemic, the tincture of the chloride of iron may be given, for a time, 
to restore the blood. Mucilage of gum arabic should be allowed for 
drink, and arrow-root for food. And to prevent a return of the hemor- 
rhage, whether active or passive, the habits and condition of the patient 
upon which the hemorrhage depends should be corrected, and the patient 
be made to conform rigidly to the laws of health in every respect. 

SECTION XV.— INTESTINAL HEMORRHAGE. 

By intestinal hemorrhage is here meant that which takes place from 
the intestinal mucous membrane, and generally from the capillary ves- 
sels, whether active or passive, to which the term melsena has sometimes 
been applied. 

We have seen in the preceding section that gastric hemorrhage is 
quite frequent. There remains for our consideration, in this section, 
the intestinal. It is very possible, however, that the blood in many 
cases escapes from the mucous membrane of the stomach and intestines 
at the same time, which fact must always be taken into account in the 
examination of such cases. 

That hemorrhage should take place from the alimentary mucous mem- 
brane is not strange when we remember that the portal system, consist- 
ing of the inferior and superior mesenteries, the splenic and gastric veins 
takes up the blood distributed to the alimentary canal and other abdo- 
minal viscera, and conducts it along the vena portse to the liver, through 
which it passes. But arrived at the liver, it must be remembered that 
the vena portse divides, first into two, and then into numerous secondary 
branches which ramify through the portal canals. In the liver its 
branches receive the venous blood from the capillaries of the hepatic 
artery, and finally terminate in the venous plexus of the lobules of the 
liver, their blood being conducted on by the interlobular to the sub-lobular 
veins, and thence through the hepatie trunks to the inferior vena cava. 

Now, any thing which hinders a free passage of the blood of the portal 
system through the liver, embracing functional and organic diseases of 
the liver, as well as obstruction in the hepatic veins or in the inferior 
vena cava, may be congesting the capillaries of the alimentary mucous 
membrane, produce gastro-intestinal hemorrhage, as we have already 
seen. But having already considered gastric hemorrhage, and remem- 
bering that it may occur with intestinal, we will now, with these facts in 
mind, pass on to the consideration of intestinal hemorrhage, the legitimate 
subject of the present section. 



INTESTINAL HEMORRHAGE. 527 

Symptoms. — It must be remembered that in addition to hepatic de- 
rangement, there are various other diseases of a general and local char- 
acter, such as scurvy, purpura, dysentery, enteritis, &c, of which 
intestinal hemorrhage is sympathetic. But intestinal hemorrhage is 
ordinarily preceded by a sense of weight, fullness, heat, and pain in the 
abdomen, and occasionally by tenderness. There may be also loss of 
appetite and various symptoms indicative of intestinal derangement, con- 
tinuing for a longer or shorter time. Finally, the patient is attacked 
suddenly with griping pain in the bowels, followed by nausea, faintness, 
paleness, cold extremities, &c, followed by a more or less copious dis- 
charge of blood from the bowels. 

In some cases, however, the hemorrhage comes on without any marked 
premonitory symptoms ; the appearance of the blood discharged from the 
bowels, together with the attendant griping, fainting, and depression, 
being the first intimation of the disease. Or the intestinal hemorrhage 
may occur to an alarming and even fatal extent, and no blood be dis- 
charged from the bowels, but such sudden and copious concealed hemor- 
rage is not, I believe, very common. 

The quantity of blood lost in intestinal hemorrhage varies from a few 
ounces to several pints or even quarts, and it varies in appearance 
according to the portion of the intestines from which it proceeds. If it 
comes from the large intestines, it is generally of a bright red color ; if 
from the small intestines, and copious, it is dark red; but if it has 
escaped from an extensive surface by slow exudation, it has a dark pitch- 
like appearance; and finally, it has the appearance of coffee-grounds if 
it has escaped in consequence of disorganization from inflammation or 
ulceration, as is sometimes the case in malignant fevers and other 
diseases. 

Anatomical Characters. — More or less blood is found in the intestines, 
and the mucous membrane presents in some cases a congested, and in 
others a pale appearance. Except in cases in which there is some intes- 
tinal organic disease, the mucous membrane presents no signs of rupture 
of its vessels, rendering it nearly certain that the blood escapes from the 
capillary vessels as is usual in spontaneous hemorrhage. 

Causes. — By far the most frequent cause of intestinal hemorrhage, as 
well as of gastric, is obstruction of the portal system, from torpor, con- 
gestion, or organic disease of the liver. But this variety of hemorrhage 
may be produced by drastic cathartics, or by any cause capable of pro- 
ducing irritation, congestion, inflammation, or ulceration of the intestinal 
mucous membrane. 

Intestinal hemorrhage may also be the result of organic disease of the 
intestines, of the heart, of the thoracic and abdominal viscera, of sup- 
pression of the menses, and finally of malignant fevers, and various dis- 
eases, such as purpura, scurvy, &c, in which there is a weak or dissolved 
state of the blood, and relaxed condition of the tissues of the body. 

Prognosis. — The prognosis in intestinal hemorrhage is generally favor- 
able, unless it is complicated with, or the result of some general or local 
malignant or organic disease. If the condition which produces it admits 
of relief, the hemorrhage once arrested, may not return. At least such 
has been the result of my observation. It should be remembered, how- 



528 DISEASES OP THE CIRCULATORY SYSTEM. 

ever, that the hemorrhage, if very copious, may prove suddenly fatal, or 
it may return from slight causes, and finally lead on to a fatal termina- 
tion. 

Treatment. — In cases of intestinal hemorrhage, the patient should be 
kept quiet, and have sinapisms applied to the feet or limbs, and also to 
the abdomen, and the irritation should be carried to a little short of 
vesication. 

Ipecac should be given in one-fourth of a grain doses every fifteen 
minutes, till the hemorrhage is arrested, or slight anusea is produced. 
In case the ipecac fails to arrest the hemorrhage, tannin or alum should 
be given in full doses every two hours, and continued till it is arrested. 

The patient should be allowed to drink freely of cold milk and water, 
and mucilage of gum arabic during the continuance of the hemorrhage, 
which will afford sufficient nourishment, unless there should be great pros- 
tration, in which case broths or wine-whey may be required. As soon as 
the hemorrhage is arrested, or nearly so, attention should be directed to 
the condition which has produced it, and which tends to keep it up, or 
would be likely to cause its return, if entirely arrested. 

If, as is often the case, there is hepatic derangement, two or three 
blue pills should be administered as soon as the hemorrhage will admit 
of it, and followed in six hours by half an ounce of castor oil. If there 
are symptoms of mucous enteritis, blisters should be applied to the epi- 
gastrium and abdomen, and the plainest variety of digestible food only 
allowed. 

Finally, if the hemorrhage has been produced by suppression of the 
menses, or by any other functional or organic derangement or disease of 
any part of the system, or from an anaemic condition, judicious measures 
should be used to restore the system to a healthy state, as far as may be, 
and thus a return of the hemorrhage be prevented, if possible. 

SECTION XVI.— HEMATURIA. 

By hematuria fromatpa, " blood," andoupfw, "I urinate," I mean here 
hemorrhage from the mucous membrane of the urinary passages, whether 
it proceed from the kidneys, ureters, bladder, or urethra, or be of an ac- 
tive or passive character. 

The mucous membrane of the urinary passages, it will be remembered 
extends from the pelvis of the kidneys along the ureters, and forms the 
lining membrane of the bladder and urethra. It is supplied freely with 
blood vessels, from the capillaries of which the blood generally escapes 
by exhalation, a rupture of the vessels being quite unusual, though an 
occasional occurrence. 

Symptoms. — Hematuria is generally preceded by a sense of fullness, 
heat and pain in the region of the kidneys, ureters, bladder, or urethra, 
followed perhaps by faintness, a bearing down sensation, pain at the 
neck of the bladder, and a disposition to micturate. On attempting to 
pass water, it is discovered to be either clear blood, or blood and urine, 
variously mingled, and of a variety of appearances, depending upon the 
copiousness of the hemorrhage, and the part of the urinary passages 
from which it has proceeded. 



HEMATURIA. 529 

If the hemorrhage is from the kidneys, the blood is generally inti- 
mately mixed with the urine, and without coagula, and the pain is re- 
ferred to the region of the kidneys. If the blood is intimately mixed 
with the urine and also contains cylindrical coagula of a bleached appear- 
ance, the pain extending from the kidney along to the bladder, the 
hemorrhage may be presumed to be from the ureters, but it is not quite 
certain. When, however, there is a free discharge of blood, or blood and 
urine, but slightly mingled, attended with fullness, uneasiness or pain 
over the pubis, in the perinseum, or neck of the bladder, with perhaps 
floating coagula, it is probable that the hemorrhage is from the bladder. 
Finally, if the fullness, heat and pain is referred to the urethra, and the 
blood passes in a stream or by drops, without a disposition to urinate, 
and the hemorrhage is suspended during micturition when it occurs, the 
blood undoubtedly escapes from the urethra. 

The quantity of blood lost in hematuria varies from barely sufficient 
to tinge the urine, or to be discoverable, to a quantity sufficient to 
endanger or even destroy life. This variety of hemorrhage is usually 
most copious in persons advanced in life, in whom it is by far the most 
liable to occur. 

Diagnosis. — To distinguish blood in the urine, the result of hsema- 
turia, from the urine tinged deep-red or brown by articles of food, or 
the result of morbid conditions of the urinary organs, or of the system 
generally, it is only necessary to observe carefully all the symptoms, 
and notice the following differences. 

Bloody urine tinges linen dipped in it red or reddish, while colored 
urine only stains it brown. Bloody urine though turbid when discharged 
generally becomes clear on standing, and the deposit is not dissolved if 
heat be applied, while colored urine though nearly transparent when 
voided, becomes more or less turbid on standing, and readily redissolves 
the sediment if exposed to heat. Finally, if blood be present in the 
urine, the microscope will readily bring to light the blood corpuscles ; 
and albumen may be detected by the application of heat or nitric acid. 

Causes. — A great variety of causes may operate to produce hsema- 
turia, among which are violent exercise, calculi in the urinary passages, 
venereal excesses, organic diseases of the urinary organs, irritating sub- 
stances, as oil of turpentine, cantharides, &c, the suppression of accus- 
tomed discharges, especially the hemorrhoidal or menstrual, and finally, 
anything which produces either a plethoric or anaemic condition of the 
system. 

We have already seen that haematuria occurs most frequently in ad- 
vanced age, and it appears to be more frequent with men than women. 
In most of the cases that have fallen under my observation, it has been 
in males past middle age ; and has appeared to be connected with a 
hemorrhagic state of the blood, and a general relaxed condition of the 
tissues of the body. In one case, which I remember, that was brought 
on by active exercise in the hay-field, there had been copious haemate- 
mesis a few weeks previous. 

Prognosis. — The prognosis in hematuria is unfavorable, if it depends 
upon organic disease of the urinary organs, or upon any local or general 
condition which does not admit of relief from proper remedial measures. 
34 



530 DISEASES OP THE CIRCULATORY SYSTEM. 

In all other cases the prognosis may be regarded as rather favorable, if 
the case be subjected to proper treatment, and the cause or causes be 
removed. 

Treatment. — If the patient is not advanced in life, and the hemorrhage 
is of an active character, general bleeding may sometimes be required, 
but not generally. Cups, however, should be applied, wet or dry, to 
the lumbar and sacral regions, and these followed by sinapisms, the warm 
foot-bath, and, if very copious, by injections of cold water, or mucilage, 
into the rectum. 

Ipecac, as in other cases of hemorrhage, may be administered in one- 
fourth of a grain doses, every fifteen minutes at first ; and in case this 
proves ineffectual, alum may be given in ten grain doses, every two or 
three hours, and continued till the hemorrhage is arrested. The patient 
should be allowed to drink freely of mucilages, and if the bowels are 
constipated, they should be moved by mucilaginous injections with a little 
castor-oil. 

In cases of passive hgematuria, warm pediluvia, dry cups and sina- 
pisms to the lumbar and sacral regions, and also to the extremities, to- 
gether with the use of ipecac, as above directed, followed by the tincture 
of chloride of iron, in ten drop doses, in mucilage, will generally do best. 
In active cases, the patient should be allowed, in addition to mucilages, 
milk and water for nourishment. But in passive cases, crust coffee, with 
milk, broths, and plain digestible food, may be allowed. 

Having once arrested the hemorrhage, the remote causes should be 
sought out and removed, and the local and general condition of the sys- 
tem upon which the hemorrhage directly depends should be corrected, 
as far as possible, by proper remedial measures, and thus a return of the 
hemorrhage be prevented. 

SECTION XVII.— HAEMOPTYSIS. 

By haemoptysis, from «u>a 3 " blood," and *tvp, "I spit," I here mean 
hemorrhage from the larynx, trachea, or lungs, whether it be from the 
mucous membrane of the air-passages, the air-cells of the lungs, or into 
the parenchyma of the lungs, constituting what has been called pulmo- 
nary apoplexy. 

If the blood escapes from the capillaries of the mucous membrane of 
the larynx, trachea, or bronchia, it is generally discharged from the 
mouth ; being raised by coughing. And a portion of it may be raised 
if it escapes into the air-cells from their capillaries. But if the bleeding 
is exclusively into the pulmonary parenchyma, or interlobular tissue, 
constituting apoplexy of the lungs, there may be no discharge of blood 
from the mouth, none being necessarily raised by coughing. 

There are a few general symptoms common to all cases of haemoptysis, 
and others peculiar to each variety, which we will now proceed to con- 
sider, first the general and then the particular. 

Symptoms. — Before an attack of haemoptysis, there is apt to be a 
sense of fullness, heat, oppression and pain in the chest, with a more or 
less distressing cough, cold extremities, a flushed face, and perhaps slight 
chills, followed by febrile excitement. In some cases, however, these 



HAEMOPTYSIS. 531 

premonitory symptoms are absent, or unnoticed ; the patient first feeling 
a tickling sensation in the larynx, trachea or lungs, with a saltish sweet 
taste in the mouth, and on coughing or hawking, or both, blood in greater 
or less quantities may be thrown from the mouth, unless the hemorrhage 
has taken place in the parenchyma of the lungs. 

The blood is generally liquid and florid, and unless the quantity is very 
great, is more or less frothy. It is, however, sometimes partially coagu- 
lated, and in haemoptysis occurring in malignant fevers, it may be almost 
black. 

The quantity of blood lost, varies from a few ounces, to a quart or 
more. And in proportion to the amount of blood, will be the dyspnoea, 
fullness, and oppression in the chest, as well as the paleness, agitation, 
and faintness, which almost invariably attend or follow an attack of 
haemoptysis. 

Haemoptysis seldom terminates fatally, at first, and a patient may es- 
cape with only one attack. But this variety of hemorrhage, is very liable 
to return, after a time, and the attacks may recur, at regular or irregular 
intervals, and finally lead on to a fatal termination; especially if, as is 
generally the case, it is connected with organic disease of the lungs, 
heart, or large arteries. 

In cases in which the hemorrhage is from the capillaries of the larynx 
the irritation is felt in that region, and the blood is thrown up by hawking, 
or by a peculiar laryngeal cough. The quantity of blood is small in such 
cases, and it has but slight, if any frothy appearance. 

Hemorrhage seldom takes place from the trachea ; but when that is 
the seat of the bleeding, the uneasiness is referred to that region ; the 
blood is fresh, but slightly frothy, and small in quantity ; and is raised 
by a cough, deeper than the laryngeal, though not pulmonary in its 
character. 

If the hemorrhage is from the bronchial tubes, as is generally the case, 
we have the general symptoms already laid down, and perhaps a slight 
dullness on percussion, as well as a feeble inspiratory murmur, replaced 
by the bronchial respiration ; a liquid bubbling rale in the larger tubes, 
and a fine liquid crepitus in the small ones. 

In case the hemorrhage is into the air-cells, from their capillaries, 
there may be a reddish, frothy, and perhaps viscid expectoration, dyspnoea, 
and a feeling of approaching suffocation, dullness on percussion over the 
affected part, and finally, a crepitant rale in the small bronchial tubes, 
and a liquid mucous rale, or rattle in the larger ones. 

Finally, if the blood escapes exclusively into the pulmonary parenchyma, 
or interlobular tissue, there is the oppression, and dyspnoea; with a 
feeling of impending suffocation, marked dullness on percussion, and in 
some cases, an absence of the respiratory murmur, in the affected por- 
tion of the lung, at least. Sometimes, however, more or less of the 
blood thus extravasated, escapes into the air-cells, and bronchial tubes, 
producing the crepitant, sub-mucous, or mucous rale, and is finally ex- 
pectorated, as in cases in which the hemorrhage is directly into the 
air-cells. 

Such then, are the general symptoms of haemoptysis, and also the 
particular symptoms of each variety, by a careful observation of which, 



532 DISEASES OE THE CIRCULATORY SYSTEM. 

correct conclusions may generally be drawn in relation to the nature and 
seat of the hemorrhage. 

Diagnosis. — To distinguish haemoptysis from bleeding of the nose, 
mouth or fauces, it is only necessary to examine these cavities carefully, 
and to note the manner in which the blood is brought to the mouth, as 
well as the sounds elicited by percussion over the affected part, and the 
change in the respiratory murmur. 

To distinguish haemoptysis from haematemesis, the changed respiratory 
murmur, the dullness on percussion, the florid appearance of the blood, 
and its being raised by coughing and hawking, instead of vomiting, 
together with all the symptoms in the case, will render the diagnosis 
clear to the careful observer. 

Anatomical Characters. — In most cases of haemoptysis, the mucous 
membrane of the air passages either appears natural or is reddened, and 
has a slight appearance of having been inflamed. If, however, the blood 
has escaped into the air cells from their capillaries, though there is no 
laceration of the vessels or the mucous coat, the air cells and smaller 
bronchial tubes are generally distended or more or less filled with blood. 
Finally, in cases in which the hemorrhage has taken place into the 
pulmonary parenchyma, constituting what has been called apoplexy of 
the lungs, there may be found a solid circumscribed portion of blood 
containing several cubic inches, of a darkish color, and of a peculiar 
granulated structure. Sometimes the clot thus found is contained in a 
large cavity which it has formed in the substance of the lungs, involving 
even one or more of the lobes, and perhaps by lacerating the pleura it 
may extend or have escaped, in part at least, into that cavity. 

Such, I believe, are the ordinary appearances presented on post- 
mortem examination, liable, of course to variations. In a fatal case that 
fell under my care a few weeks since, of a decidedly passive character, I 
have reason to believe that the clot occupied a large part of the superior 
portion of the right lung ; and though some frothy blood escaped by ex- 
pectoration, the lung was never cleared; the blood expectorated appear- 
ing to be only the result of an oozing into the air cells and bronchial 
tubes from the circumference of the clot. In another fatal case that fell 
under my care in this village, occurring during the second chill in a 
congestive ague, there was no expectoration of blood, the patient sinking 
in about twenty-four hours, with all the symptoms of pulmonary 
apoplexy. 

Causes. — The most frequent causes of haemoptysis are suppression of 
habitual or accustomed discharges, such as the hemorrhoidal or men- 
strual, tubercular phthisis, organic diseases of the heart, aneurism of the 
large vessels, and congestion, irritation, or inflammation of the mucous 
membrane of the larynx, trachea, or bronchial tubes. 

But haemoptysis may be produced by external violence, lifting or 
violent exercise, imprudent laughing, loud speaking, singing, &c. ; the 
breathing of very hot or cold air, metastasis of gout, rheumatism, or 
cutaneous eruptions, the drying up of old ulcers, constipation of the 
bowels, mental excitement, and finally, by any causes which produce 
either a phlethoric or an anaemic, debilitated, and relaxed condition of 
the system. 



HAEMOPTYSIS. 533 

Prognosis. — In all cases of haemoptysis in which the morbid condition 
of the system upon which it depends, whether local or general, is of a 
character that admits of correction, the prognosis is favorable, if the case 
can have the benefit of judicious medical treatment, and the patient can 
be made to conform to the laws of health and propriety in every respect. 

But in all cases of haemoptysis depending upon, or connected with or- 
ganic disease, and especially if there is, as is generally the case a scro- 
fulous or tuberculous condition, the prognosis is decidedly unfavorable, 
as the patient will generally die sooner or later with tubercular phthisis. 

Treatment. — When an attack of haemoptysis occurs, the patient should 
be placed in a quiet easy position, with the head and shoulders elevated, 
and as it is always at hand, and generally salutary in its effect, a tea- 
spoonful of common salt should be given to the patient at once, and re- 
peated in half an hour if the hemorrhage continues. 

If the hemorrhage is active, the patient being of a robust plethoric 
habit, general bleeding may be indicated, and when it is, should be re- 
sorted to at once. After general bleeding, when it is indicated, and at 
first when it is not, cups wet or dry may be applied to the chest, and the 
feet of the patient should be placed in warm water. 

While this is being done, ipecac in one-fourth of a grain doses should 
be administered every fifteen minutes, as in other cases of hemorrhage, 
and continued till the hemorrhage ceases, or nausea is produced. If, 
however, the treatment thus far has not arrested the sanguineous dis- 
charge, ten drops of the oil of turpentine may be given every two hours, 
and alternating with this, ten grains of ergot, or half a drachm of the 
fluid extract may be given, and continued for a reasonable time. Finally, 
if the hemorrhage still lingers, tannin may be given in two grain doses 
at longer or shorter intervals, and continued till it is arrested. 

The bowels should be kept regular if necessary by Seidlitz powders, 
or small doses of the sulphate of magnesia, and the patient should be 
nourished by the plainest articles of digestible food. But if as is more 
generally the case, the hemorrhage is of a passive character, depending 
upon congestion ; measures should at once be taken to equalize the cir- 
culation. The feet should be placed in warm water, stimulating friction 
should be made along the spine, and sinapisms applied to the chest and 
extremities. 

The chloride of sodium followed by the ipecac should be given as di- 
rected in active cases, and on the suspension of the ipecac, two grains of 
tannin may be given every two hours for a time, and then every four or 
six hours, while it may be required. If, however, the case passes on, the 
hemorrhage continuing, or returning often, ten drop doses of the tinc- 
ture of the chloride of iron may be given every six hours, and alternat- 
ing with this, the same quantity of the balsam of Peru, rubbed up with 
brown sugar, and water added so as to make a teaspoonful a dose. I 
have succeeded with these measures after others had entirely failed. 

The bowels should be kept regular, by a pill of aloes and rhubarb at 
evening, if necessary, and the patient should be allowed a good nourish- 
ing but digestible diet, to be taken with regularity. 

After arresting the flow of blood in haemoptysis, the remote causes 
and morbid condition of the system upon which it depends should be 



534 DISEASES OF THE CIRCULATORY SYSTEM. 

sought out, and removed as far as possible. The patient should be made 
to conform to the laws of health, and to rules of propriety in every re- 
spect, and if the morbid condition of the system upon which the he- 
morrhage directly depends admits of removal, it should be done as fast 
as possible by judicious measures. If, however, as is often the case, it 
is connected with organic disease, such palliative measures as may be 
indicated should be resorted to, and continued while they afford any 
considerable relief. 

SECTION XVIII.— METRORRHAGIA— ( Uterine Hemorrhage.) 

By metrorrhagia, from /M?rpa, "the womb," and pjjyw/**, "I break 
forth," is here meant uterine hemorrhage, whether occurring at the 
menstrual or at other periods, provided it be the result of a morbid con- 
dition, and if occurring at the menstrual period, in excess. 

Uterine hemorrhage generally takes place from the lining mucous 
membrane of the uterus, and may occur in the unimpregnated or im- 
pregnated state of the organ. But as hemorrhage occurring in connec- 
tion with pregnancy belongs rather to the obstetrician, I shall consider 
here, more especially, hemorrhage of the uterus as it occurs in the un- 
impregnated state, noticing, however, briefly as we pass, such cases as 
most frequently occur in connection with the impregnated state of the 
organ. 

Uterine hemorrhage is liable to occur at any time during pregnancy, 
but more especially at the close of each month, at the time when men- 
struation would have occurred, if conception had not taken place, and 
finally, at or immediately after delivery. 

In the unimpregnated state, uterine hemorrhage may occur at any 
period of life, but more generally between the first appearance and final 
cessation of the menses ; and during this time, by far the most frequently 
at the menstrual periods, and at or near the final cessation of the men- 
strual functions. 

Metrorrhagia, like other varieties of hemorrhage, is either active or 
passive, and is attended with a train of general and particular symp- 
toms, which we will now proceed to consider. 

Symptoms. — Metrorrhagia is generally preceded by a sense of weight, 
fullness, heat, and pain in the uterus, as well as pain in the loins, more 
or less bearing down, slight swelling of the breasts, and of the external 
parts of generation, impaired digestion, headache, and mental disturb- 
ance, and finally by ringing in the ears, an irregular pulse, and some- 
times slight chills, followed by flushes of heat. 

After these symptoms have continued for two or three days, the he- 
morrhage occurs, sometimes with violence so as to produce great pros- 
tration, syncope, &c. More generally, however, it is moderate at first, 
and gradually increases, with relief of the premonitory symptoms, till 
finally, unless arrested, it leads on to fainting, prostration, cold extre- 
mities, and sometimes to a fatal termination. 

If the hemorrhage occurs at the menstrual period, the flow at first 
generally has the appearance and properties of the menstrual flux. And 
menstruation may pass on quite regularly, to near its proper time for 



METRORRHAGIA, bdb 

when there is the sudden or gradual supervention of the he- 
morrhage, the blood coagulating, and the flow being attended with all 
the usual symptoms of uterine hemorrhage, as it occurs disconnected 
with menstruation. 

Women subject to metrorrhagia are less liable to become pregnant, 
and when they do, being predisposed to hemorrhage, are in danger of 
its return any time during the period of utero gestation ; but especially 
at the close of each month, at which time there is, I believe, with most 
women a tendency to menstruate, for the first few months at least. 
The symptoms attending such cases do not differ materially from those 
attending metrorrhagia, occurring in the unimpregnated state, only so far 
as they are influenced by the abortion, should that misfortune occur, as 
it is liable to. Finally, excessive uterine hemorrhage is liable to occur 
at or immediately after delivery, whether it be premature or at full time, 
attended with sinking, faintness, cold extremities, and, unless arrested, 
followed by distressing, and even fatal prostration. 

Metrorrhagia occurring at or near the final cessation of the menstrual 
function, is apt to be very irregular in the period of its return, and of 
various duration. In some cases it may be slight, but generally it is 
profuse, protracted, and troublesome, being usually of a passive cha- 
racter. It is most liable to occur in women that have had frequent or 
protracted metrorrhagia, with perhaps abortions, during the continuance 
of the menstrual function. Its symptoms are those already laid down 
as belonging to uterine hemorrhage, with the supervention or addition, 
in many cases, of various hysterical or nervous phenomena. 

Such, I believe, are the usual symptoms, general and particular, of 
metrorrhagia or uterine hemorrhage ; liable, of course, to variations, 
depending upon the active or passive character of the hemorrhage, as 
well as other modifying influences. 

Causes. — Metrorrhagia may be produced by a plethoric or anaemic 
condition, by organic diseases of the uterus, or by any causes which pro- 
duce a congestion of, irritation in, or a determination of blood to the 
uterus, or its lining mucous membrane. 

The causes which operate to produce a plethoric hemorrhagic condi- 
tion, are the use of too stimulating food and drinks, want of exercise, 
hot rooms, hot beds, &c. 

Among the causes that operate to produce the anaemic hemorrhagic 
state, are insufficient or unwholesome food, impure air, various privations, 
such as exposure to cold, filth, dampness, &c, and finally, any cause that 
depraves the blood or relaxes the tissues of the body. 

The organic diseases, such as cancer, polypus of the womb, &c, which 
produce a hemorrhagic state of the organ, are generally the result of 
hereditary or acquired general or local depravity of the system. They 
depend upon a variety of remote causes, some of which may have been 
operating through several preceding generations. Finally, among the 
causes that produce the hemorrhagic state of the organ, by causing con- 
gestion, irritation, or a determination of blood to the uterus, are sexual 
excesses, abortions, constipation of the bowels, obstructions of the portal 
circulation, leucorrhoea, pregnancy, delivery, &c. 

And, besides, there are other occasional causes which operate more 



536 DISEASES OF THE CIRCULATORY SYSTEM. 

especially by producing a determination of blood to the uterus, such as 
riding on horseback, menstruation, mechanical violence, the exciting 
passions, and finally, drastic cathartics and emenagogue or other medicines 
■which irritate or excite the uterus, rectum, or urinary organs. 

Prognosis. — The prognosis is unfavorable in all cases of metrorrhagia 
depending upon causes and morbid conditions that do not admit of re- 
moval or relief, such as the various organic diseases of the uterus, &c. 
But the prognosis is generally favorable in uterine hemorrhage depending 
upon causes and conditions that admit of removal or correction, provided 
the case be subjected to proper treatment, and the patient can be made 
to conform to the laws of health and rules of propriety in every respect. 

Treatment. — In all cases of metrorrhagia, the patient should be kept 
quiet in the recumbent posture, and allowed good fresh and moderately 
cool air. If the hemorrhage is active, general bleeding may be of service 
in some rare cases, but not generally. After general bleeding, when it 
is required, and at first, when it is not, cups, wet or dry, may be applied 
to the sacrum, and the ipecac administered as in other cases, in \t\i of a 
grain doses every fifteen minutes till the hemorrhage is checked or nausea 
produced. Alum should be given from the first, even while the ipecac 
is being administered, in ten grain doses every hour, in a wine-glassfull 
of milk and water, and continued thus till the hemorrhage is materially 
checked, when it should be continued every four or six hours, alternating 
with two grains of tannin, and this treatment should be continued till the 
hemorrhage is arrested. 

If the bowels are constipated, they maybe moved by injections of cool 
water, or if necessary by moderate doses of the sulphate of magnesia. 
The patient should be allowed, during the continuance of the hemorrhage, 
to drink freely of cold milk and water for nourishment, and during con- 
valescence, a plain, digestible and unstimulating diet should be enjoined. 

In cases of active metrorrhagia in which the hemorrhage is copious and 
not arrested in a reasonable time by other measures, a fine silk or cambric 
handkerchief, previously dipped in cold water or a saturated solution of 
alum, should be gradually passed into the vagina, so as to reach the os 
uteri. The tampon thus introduced may be allowed to remain, if neces- 
sary, for twenty-four hours; and should it be necessary, another may be 
introduced on its removal. 

In cases of passive metrorrhagia, after placing the patient in the re- 
cumbent position, in fresh moderately cool air, and administering the 
ipecac in one-fourth of a grain doses every fifteen minutes, as in other 
cases of hemorrhage, and giving the alum in ten grain doses in milk and 
water, every hour for a time ; tannin and tincture of chloride of iron 
should be resorted to. 

Two grains of tannin may be given every four or six hours, and alter- 
nating with this, ten drops of the tincture of chloride of iron, and this 
should be continued till the hemorrhage is arrested, when the tannin 
should be omitted, and the iron continued in ten drop doses three times 
per day, till the anaemic condition is corrected. In case, however, the 
patient is not decidedly ansemic, a fluid drachm of the tincture of 
cinnamon may be given at first, alternating with the tannin instead of 
the iron, and the chalybeate omitted till the hemorrhage is arrested, 



SCORBUTUS. 537 

when it may be given, three times per day, for a time, if required by the 
state of the blood. 

The patient should be kept comfortably warm, and should be allowed 
to drink freely of milk, or milk and water, and if the appetite calls for 
it, a good digestible, and nourishing diet may be allowed. Should the 
tampon become necessary, in cases of passive metrorrhage, the handker- 
chief should be passed dry, and changed as often as once in twenty-four 
hours, while it may be required. 

Such are the general principles which should guide us in the treatment 
of metrorrhagia, subject of course to modifications. And as some of these 
modifications are of importance, we will give them a passing considera- 
tion. 

In cases of uterine hemorrhage following a nearly natural menstrual 
period, I believe that remedies should be withheld till a reasonable flow 
has taken place, and clots begin to form, at which time judicious mea- 
sures should be taken for its arrest on the principles already suggested. 

In cases of metrorrhagia occurring during pregnancy, the patient should 
be kept quiet, allowed plain unstimulating food, and cool drinks, and if 
medical treatment becomes necessary, five grains of Dover's powder may 
be given every six hours, the bowels being kept moderately loose by 
small doses of cream of tartar. 

In cases of excessive uterine hemorrhage following delivery, whether 
premature or at full time, the foot of the bed on which the patient is 
lying should be elevated, at least eighteen inches, contraction of the 
uterus should be sought by smart friction over the abdomen, and if neces- 
sary by the introduction of the hand, well oiled into the uterus, and the 
alum should be given in ten grain doses, every hour in a wine glass of 
milk and water. In such cases, if faintness, and great prostration oc- 
curs, brandy should be freely administered, and as soon as possible, the 
patient should drink freely of good new milk. 

Finally, in metrorrhagia occurring at or near the final cessation of the 
menstrual function, the general principles already laid down will usually 
apply. But great care should be taken, not only in these cases, but in 
every variety of uterine hemorrhage, to correct as far as possible, the 
morbid general or local condition upon which it depends. And then, 
having also corrected the habits of the patient, the system may regulate, 
and a tolerable degree of health be secured, if there is no organic uterine 
disease. 

SECTION XIX.— SCORBUTUS— (Scurvij.) 

By scorbutus or scurvy is here meant that peculiar debilitated condi- 
tion of the system in which there is a depraved state of the blood, a 
hemorrhagic tendency, and a state of congestion or passive inflammation 
of different parts of the body, and especially of the gums, without any 
marked febrile excitement. 

When persons are exposed for a long time to hardships, impure air, 
and almost exclusive salt meats, without vegetable food, the assimilative 
functions become deranged, and the blood dissolved, developing this dis- 
tressing affection called scurvy. 



538 DISEASES OF THE CIRCULATORY SYSTEM. 

This disease may occur at any place, where the train of circumstances 
which lead to it prevail. It is more common, however, among seamen 
on long voyages, or in armies on long and tedious marches, where the 
causes which lead to it generally exist, in a greater or less degree. I 
have met with it, however, under other circumstances ; but happily the 
disease is now getting quite rare. 

Symptoms. — Scurvy generally makes its appearance gradually, com- 
mencing with a degree of lassitude and want of muscular power. As 
the debility increases, there is a stiffness of the joints, and especially of 
the feet and knees. By degrees there is an inability or disinclination 
to corporeal exertion, and the respiration becomes short, and panting 
from very slight bodily exertion. 

The countenance becomes pale and sallow, or lead-colored, and has a 
bloated appearance. The skin is dry, tense, and shining, and separates 
in scales on different parts of the body. Livid spots make their appear- 
ance on the legs or thighs, and finally, on the abdomen and arms ; and 
generally in connection with the appearance of these spots there is more 
or less ©edematous swelling of the feet and legs. 

With the appearance of the spots on the skin, the breath becomes fetid, 
and the gums tender and spongy, and apt to bleed, on being slightly 
bruised or touched. The patient complains of a putrid taste, and has a 
strong craving for fresh vegetable food, and acid drinks. 

The urine becomes dark-colored ; vision is imperfect ; and the muscu- 
lar powers are often so prostrated, that the patient can hardly maintain 
the erect position. The blood becomes dissolved and dark, the pulse 
weak and soft, and, as the disease advances, the stiffness of the joints 
increases, induration of the muscles occur, there are violent pains in the 
knees, back, and loins ; and there is apt to be spasmodic pains in the 
bowels, with constipation or diarrhoea. 

The respiration becomes more oppressed, subcutaneous extravasation 
of blood takes place on different parts of the body, passive hemorrhages 
occur from the gums, nose, rectum, bladder, &c, at the same time that 
ulcers form on the calves of the legs and thighs, exhibiting an cedema- 
tous appearance, with irregular edges, and discharging a reddish bloody 
fluid. 

The gums separate from the teeth and slough, the teeth become loose 
and drop out, old wounds re-open, the bones become brittle, and syncope 
occurs on very slight corporeal exertion. Finally, if the disease passes 
on unchecked, the respiration becomes fatiguing, syncope occurs while 
the patient is at rest, or from the slightest exertion ; a fetid effluvium 
exhales from the body ; emaciation progresses rapidly ; paralysis may 
occur ; and at last, with dropsical effusions, a colliquative diarrhoea, coma, 
and perhaps convulsions, the patient expires. 

Such, I believe, are the usual symptoms of scorbutus, or scurvy, in its 
worst forms. But it should be remembered that the disease is sometimes 
much milder, being attended only with debility, a fetid breath, spongy 
gums, oedema of the feet, dark spots on the legs, from extra vasated blood, 
and various other kindred symptoms, the patient being able to keep about 
most of the time. 

Anatomical Characters. — There is generally found on post-mortem ex- 



SCORBUTUS. 539 

animation more or less watery blood, extravasated into the various tissues 
of the body, and also collected in the different cavities. Ecchymoses ap- 
pear not only on the surface of the body, but also on the serous and mu- 
cous membranes. The periostium is sometimes found separated from the 
bones, and the bones detached from their cartilages and epiphyses. 

The blood is almost invariably found in a dissolved state. The heart 
and muscles generally are pale and flabby, and are sometimes so soft that 
they may be broken down between the fingers. Finally, marks of passive 
inflammation are occasionally detected in various parts or tissues of the 
body ; but this is by no means constant, and may be an accidental com- 
plication of the disease when it exists. 

Diagnosis. — If all the symptoms, together with the extrinsic circum- 
stances, be taken into account, there can be little or no difficulty in dis- 
tinguishing scurvy from purpura, and other kindred diseases, which it 
may in a slight degree resemble. 

Purpura, it should be remembered, though it has the dark spots upon 
the surface, from subcuticular extravasation of blood, wants most of the 
more urgent symptoms of scurvy, such as the appearance of the gums, 
the marked change in the muscular structures, the separation of the car- 
tilages and epiphyses of the bones, &c. 

Causes. — It is probable that scurvy is the result of fatiguing labor, 
damp, impure air, the use of innutritious, putrid and unwholesome food, 
especially of salt meats, to the exclusion of fresh vegetables, fruits, &c, 
great anxiety of mind, the use of intoxicating liquors, &c. But among 
these causes, the exclusion or want of vegetables and fruit, as food, 
damp, impure air, and fatiguing labor, with anxiety of mind, are prob- 
ably by far the most frequent causes of this disease. It is possible also 
that idio-miasmata may operate either directly or indirectly to produce 
this disease. 

Prognosis. — The prognosis is favorable in the early stages of the dis- 
ease, if the causes and unfavorable circumstances which have produced 
it, can be removed or corrected. But in very advanced stages of bad 
cases, the prognosis is unfavorable, as the total depravity of the blood, 
and the partially disorganized state of the tissues, may not admit of cor- 
rection by remedial measures. 

Pathology. — Scurvy evidently consists in a dissolved state of the blood, 
and consequent derangement of the tissues of the body, together perhaps 
with a deficiency of potassa in the system generally, as recently sug- 
gested by Dr. Garrod of London. 

Treatment. — The indications of treatment, then, in scurvy are very 
plain. The patient should, if possible, be allowed good dry air, the free 
use of fresh animal and vegetable food, acid drinks, and especially lemon- 
juice, and be placed in circumstances where he will preserve a cheerful 
and hopeful temper of mind. 

Lemon-juice should be freely administered to the patient in the usual 
form of lemonade. And the vegetables which contain potassa, such as 
potatoes, cabbage, radishes, lettuce and onions, should be allowed freely 
with any wholesome and digestible varieties of animal food. In case 
emons are not at hand, an ounce of citric acid may be dissolved in a pint 
of water and given instead, in half ounce doses, three times per day, 
ell diluted and sweetened, if agreeable to the patient. 



540 DISEASES OF THE CIRCULATORY SYSTEM. 

In most cases, this course of treatment will effect a cure if resorted to 
in season. But in case these measures are insufficient, potassa should be 
furnished directly to the system in the form of nitrate of potassa. Half 
a drachm of the nitre may be given four times per day in half a pint of 
gruel or crust coffee. Or if the patient takes sufficient nourishment at 
meals, two drachms of nitre may be dissolved in half a pint of vinegar, and 
two fluid ounces given every six hours with about twice the quantity of 
water. As a wash for the mouth and gums, water acidulated with muriatic 
acid and sweetened with honey will generally do well. Finally, if a trouble- 
some diarrhoea supervenes, tannin should be administered till it is ar- 
rested. 

SECTION XX.— ANEMIA— (Chlorosis.) 

By anaemia from a, privative, and a^a, "blood," is here meant want of 
blood, or a watery state of the blood, in which there is a diminution of 
its nutritive properties, and especially of the red corpuscles, the chronic 
form of the disease having been called chlorosis, from xxwpos " green," on 
account of the greenish tinge of the skin in such cases. 

The quantity of blood in the human system is probably about " one- 
eighth of the weight of the body."* And the average proportion of each 
of the organic elements in 1000 parts of healthy blood has been estimated 
at fibrin 3, red corpuscles 127, solid matter of the serum 80, and water 
790. Now in anaemia or chlorosis there is an increase in the proportion 
of water, and more or less diminution in the proportion of the red cor- 
puscles, constituting with other attendant imperfections, a greater or less 
degree of poverty of the blood. 

Acute anaemia may occur in males or females, and at any age, being 
the result generally of excessive hemorrhage, starvation, &c, the symp- 
toms of which are well understood and need not occupy our time. But 
chronic anaemia or chlorosis occurs more frequently in females, and gene- 
rally in young unmarried females, at or about the time of the establish- 
ment of the menstrual function. 

Chronic ansemia or chlorosis is attended with a long train of distress- 
ing symptoms which we will now proceed to consider. 

Symptoms. — After a partial loss of appetite and a feeling of debility 
has continued for a time, the patient exhibits a peculiar pallid appear- 
ance. The lips especially become pale and bloodless, there is puffiness 
of the eye-lids, and generally a slight appearance of tumidity of the 
face. The lower eye-lids are apt to be encircled with a streak of a dark 
leaden color, and sometimes the lips exhibit a greenish yellow tinge. 
As the blood becomes more impoverished, the whole surface of the 
body becomes pale; presenting a white, puffy and flabby appearance, 
with more or less oedema, especially of the ankles. The tongue pre- 
sents a bloated appearance, the papillae being enlarged, and its surface 
covered with a transparent mucus. The gums and internal surface of 
the cheeks are tumid and pale, and the breath is generally offensive. 

From the first, a feeling of general languor prevails, with great indis- 
position to corporeal and mental exertion. There is a headache, ringing 
in the ears and vertigo ; and the patient is apt to be drowsy, peevish and 
spiritless. 

* See Draper's Physiology, page 113. 



ANEMIA. 541 



There may be pain in the hypochondriac regions, with cough, dyspnoea, 
palpitation, syncope, &c. There is an irregular appetite, with craving 
for particular kinds of food. The bowels are torpid, with occasional 
attacks of diarrhoea, the urine is thick and sediinentous, the menses either 
have not appeared, or else if they have, are irregular or suppressed; and 
if the anaemic condition continues, the prolabia and tongue assume a pale 
lilac appearance, leucorrhcea supervenes, and emaciation gradually pro- 
gresses with all its attendant symptoms. 

In some cases there is an enlargement of the thyroid gland, a projec- 
tion of the eye-balls, giving them an enlarged and wild appearance ;* 
and there may be detected, by careful auscultation, various arterial and 
venous murmurs. If the ear be placed a little to the left, and near the 
superior part of the sternum, over the origin of the aorta and pulmonary 
arteries, a murmur is detected, sometimes resembling the blowing of a 
pair of bellows, " the bruit de souflet ;" or it may be rough like that of 
filing or sawing, " the bruit de rape" or " bruit du scie." 

If a stethoscope be applied lightly to the side of the neck, over the 
jugular vein, a peculiar, continuous " humming murmur" is heard, which 
ceases, however, if the pressure be either greatly increased or entirely 
removed. 

These arterial and venous anaemic murmurs, doubtless depend upon a 
watery state of the blood, in consequence of which its particles move 
more easily over each other, and in part perhaps upon its accelerated 
motion ; together, in the venous murmurs, with the gentle pressure made 
over the vein. 

Such, according to my observation, are the ordinary symptoms of 
anaemia, and especially of the chronic form of the disease which has been 
called chlorosis. 

Diagnosis. — Chlorosis may be distinguished from organic diseases of 
the liver, heart, and other internal organs by attention to the following 
differences : 

In organic diseases, the pallid countenance is apt to be changed occa- 
sionally to a slight flush of the cheeks, and there is not that bloodless 
lilac hue of the prolabia, so common in chlorosis. From organic hepatic 
disease, chlorosis differs in not being attended with the icteric appearance 
of the eyes, the clay-colored stools, the bilious urine, and the tenderness 
and fullness of the right hypochondrium ; all of which symptoms may 
attend organic disease of the liver. Anaemia or chlorosis may be dis- 
tinguished from organic disease of the heart by the manner of its 
approach, by the yellow or greenish appearance of the countenance, and 
finally, by the anaemic arterial and venous murmurs; which symptoms 
are not necessarily connected with organic cardiac disease. 

Causes. — The causes of acute anaemia are generally loss of blood, 
starvation, or some other sudden interruption to digestion and sanguifica- 
tion. But the chronic form of the disease, or chlorosis, maybe produced 
by a great variety of causes, such as sedentary habits, impure air, un- 
wholesome and indigestible food, want of cleanliness, protracted lacta- 
tion, menorrhagia, leucorrhcea, &c. 

The disease is probably, however, more frequently produced by ex- 

* The eye-balls are not enlarged in such cases, only appearing so from their prominence. 



542 DISEASES OF THE CIRCULATORY SYSTEM. 

hausting labor, protracted constipation of the bowels, the non-appearance 
or suppression of the menses, masturbation, the depressing mental affec- 
tions, and finally, unsatisfied sexual desires. 

Nature. — In relation to the nature of this affection there is no room 
for doubt. From whatever causes produced, the disease is evidently one 
of poverty of the blood, there being an increased proportion of water, 
and a diminished proportion of the red corpuscles, with other attendant 
imperfections of the blood; and to render the pathology of this affection 
plain, it is only necessary to remember that the blood in a healthy state 
of the system is derived chiefly from the chyle, and that it enters every 
organ and tissue of the body, distributing nutritive properties to every 
texture, sustaining the functions of every organ, and being the source of 
every secretion. 

Let, now, an excessive loss of blood take place, or digestion or sangui- 
fication be interrupted by any cause, there is not only the loss of the 
nutritive properties of the blood, as we have seen, but there is a rapid 
dilution caused by the water which enters the circulation, and hence, all 
the symptoms which attend the disease. 

And finally, when we remember that it is through the influence of the 
brain and nervous system that the voluntary and vital functions are 
sustained, and that the blood is the proper stimulant of the nervous 
system, by virtue of which, the nervous influence is generated and dis- 
tributed, it is not strange that this poverty of the blood should affect, 
as it evidently does in this disease, every function of the body, developing 
the symptoms which arise. 

Treatment — In acute cases of anaema caused by excessive loss of 
blood, or sudden suspension of digestion or sanguification, the patient 
after being resuscitated, if from hemorrhage by proper measures, should 
be placed in the recumbent posture, and kept quiet. A good supply of 
proper nourishing food to be taken with regularity should be allowed, and 
recovery will generally pass on steadily till health is restored. 

In case, however, the anaemic condition continues, and in all cases 
that have not been acute, constituting the chronic chlorotic form of the 
disease, the causes should be removed, and any local or general condition 
of the system which may have produced it, or is keeping it up should be 
sought out and removed or corrected. 

The patient should have the benefit of good air, agreeable society, suffi- 
cient exercise, and a good nourishing diet. And if there are no local 
derangements which hinder, these measures alone may be sufficient to 
effect a cure. 

If, however, the disease passes on, or there are local or functional de- 
rangements to be corrected, such as constipation, amenorrhoea, or other 
menstrual derangements, proper measures should be resorted to for their 
correction. And when the digestion, menstrual, and other functions have 
been thus corrected, the patient in addition to a good nourishing diet, 
should take some preparation of iron, either the citrate, carbonate, sul- 
phate, tincture of the chloride, or syrup of the iodide, as they may ap- 
pear to be indicated, in moderate doses three times per day, with a pill of 
aloes and rhubarb at evening, till the blood is restored. 



HYDROPS. 543 

SECTION XXI.— HYDROPS— {Dropsy.) 

By hydrops, dropsy, I mean here a preternatural collection of fluids, 
of a serous character, derived from the blood, either in the cellular or 
other loose tissues of the body, or else in one or more of the cavities. 

TVe have seen in a preceding section that the capillary vessels connect 
the extreme arteries with the minute veins in every part of the system, 
being about 3V of an inch in length, and 30V0 °f an i ncn i* 1 diameter. 
And also that the extreme arteries or arterial capillaries allow the transu- 
dation of nutritious properties from the blood, while the minute veins, 
or the venous portion of the capillaries absorb, together with the lym- 
phatic vessels, various fluids presented to them, the result of the break- 
ing down of the old tissue. 

Now, this process of exudation and absorption is going on, not only in 
the tissues where nutritious matter is required, but there is an exhalation 
from the capillaries at the surface of the mucous and serous membranes, 
and skin, as well as an ability on the part of the venous portion of the 
capillaries, to absorb fluid matters presented to them. This function the 
minute veins probably hold in common with the lymphatics, which arise 
as well from the surface of the skin, mucous and serous membranes, as in 
the tissues of the organs throughout the body. 

It matters not whether this exudation from the minute arteries, and 
arterial portion of the capillaries, as well as absorption or imbibition by 
the minute veins and venous portion of the capillaries, takes place 
through imaginary exhalant and absorbent vessels in the arterial and 
venous portion of the capillaries, or whether it be by exosmosis and 
endosmosis through the walls of these vessels. In whatever way it is 
performed there is in a state of health a perfect balancing of these influ- 
ences ; so that by the aid of the lymphatic system, there is no morbid 
collection of serous or other fluids, either in the areolar and other loose 
tissues, or in the mucous, serous, or other cavities of the body. 

But if, as is sometimes the case, these minute arteries, veins, and 
capillaries become debilitated and relaxed, or lose their proper tone, and 
at the same time the blood becomes weak or watery, more or less of the 
serum or water of the blood exhales into the cavities of the body, and 
perhaps filters through the minute arteries, and arterial portion of the 
capillaries, into the areolar tissues. Now this relaxed or debilitated 
state of the minute veins, and the venous portion of the capillaries, gene- 
rally disqualifies them for imbibing or absorbing this exhaled or trans- 
uded serum, as well on the serous surface of the cavities, as in the areolar 
tissue of the body. And as there is an increased exhalation or transuda- 
tion from the extreme arteries and their portion of the capillaries, with 
diminished absorption or imbibition by the minute veins, and their por- 
tion of the capillaries, dropsical accumulations take place, unless the 
lymphatic vessels are able by an increased action to effect its removal. 

But if, as is often the case, the lymphatics are also in a debilitated 
or topid state, the exhaled or transuded serum goes on accumulating, if 
it be in the cellular or other loose tissues of the body, till there is a 
general bloated or anasarcous state of the body. Or if the serous exha- 
lation takes place into a serous cavity, as that of the peritoneum, pleura, 



544 DISEASES OF THE CIRCULATORY SYSTEM. 

pericardium, or arachnoid of the brain, it may go on accumulating till 
the cavity is filled, and the membrane and entire parietes of the cavity 
distended to its utmost capacity, developing the symptoms of ascites, 
hydrothorax, hydrocephalus, or hydropericardium ; as the accumulation 
takes place in the one or the other of these cavities. 

Hydrops or dropsy, then, consists in a deranged or morbid condition 
of the minute arteries, veins, and capillaries, and generally of the lym- 
phatic vessels, as well as of the blood itself, involving an exhalation or 
transudation of serum from the watery blood, through the minute arte- 
ries and their half of the capillaries, and a failure on the part of the 
minute veins, and their half of the capillaries, as well as of the lympha- 
tics, to absorb or take it up. Hence the general or local dropsical accu- 
mulations which occur. 

Dropsy of this character may be the result of any cause or train of 
influences that lead to a watery state of the blood, and a debilitated or 
relaxed condition of the tissues of the body, the vascular system being 
always involved. 

I shall therefore call all cases of dropsy occurring in this manner, 
without any increased action of the vascular system, from inflammation 
or other causes, passive, while cases, though perhaps not widely different 
in their real pathology, attended with an apparent increased action of 
the vascular system, whether the result of inflammation or other morbid 
conditions, I shall call active dropsy, as a matter of convenience. 

In relation to the manner in which active dropsy takes place, and 
especially that which follows inflammation, there may be room for some 
little doubt. But as in all cases of inflammation there is either an active 
or passive congestion of the capillary vessels, and as they are enlarged 
or dilated, and finally debilitated, probably in every case, and as the 
effusion generally takes place as the inflammation subsides, it appears 
probable that the dropsical accumulation takes place in a manner very 
similar to, if not identical with, passive cases. The local pathological 
condition being in every respect the same, but the general condition of 
the system being widely different, as we have already seen. 

Such, I believe, is the real pathological condition in dropsy, whether 
connected with an active or passive condition of the circulatory system, 
the general symptoms of which we will now proceed to consider, both in 
its active and passive form. 

Symptoms. — In cases of active dropsy, whether the result of some 
local inflammation, or of a local congestion, with general irritability, 
there may be a frequent, full and active pulse, a flushed or healthy ap- 
pearance of the countenance, considerable muscular strength, and a 
tolerable condition of the digestive and assimilative functions. 

But in passive cases, the face and surface generally is pale, the extre- 
mities are cold, the pulse feeble, the muscles relaxed and weak, and there 
is a general anaemic condition, with more or less derangement of the 
digestive and assimilative functions, and especially is there imperfect 
sanguification. 

In both active and passive cases, there is apt to be thirst, constipation 
of the bowels, deficient perspiration, with a dry rough state of the skin, 
and a scanty and more or less changed state of the urine. In some cases 



HYDROPS. 545 

the urine contains albumen, which may be detected by exposing it to 
heat or nitric acid, in which case its coagulation produces more or less 
cloudiness in or gelatin iz at ion of the mass so exposed. 

Finally, the accumulated serous fluid, whether it be general or local, 
though liable to variation, has generally a limpid or slightly yellowish 
color, and little or no smell. It may, however, be tinged with blood, or 
have a milky appearance, and it very rarely contains flakes of coagu- 
lated matter or even pus. 

As the dropsical accumulation increases, whether it be anasarca, 
ascitis, hydrocephalus, hydrothorax or hydropertcardium, which consti- 
tute the varieties that I propose to consider, there are various local and 
general symptoms developed, some of which are of the most distressing 
character, arising from the local and general derangement which the 
dropsical accumulation produces. These symptoms are, however, pecu- 
liar in each variety, and will be noticed in the following sections, in con- 
nection with the variety of dropsy to which they belong. 

Causes. — Passive dropsy may be produced by any cause or train of 
causes that lead to a watery state of the blood, and a relaxed condition 
of the tissues of the body, such as excessive loss of blood, insufficient or 
unwholesome food, exposure to damp, cold, or impure air, insufficient 
clothing, impaired digestion, and defective sanguification, the use of 
tobacco, sexual excesses, the use of alcoholic drinks, and a variety of ex- 
hausting diseases, such as phthisis, scrofula, scurvy, &c. 

Active cases of dropsy may be produced by any cause or train of 
causes which produce either local inflammation, or irritation, with con- 
gestion ; attended with a morbidly irritable or excited condition of the 
circulatory system, such as sudden exposure to cold, the retrocession of 
cutaneous eruptions, the suppression of accustomed discharges, as the 
menstrual or hemorrhoidal ; the puerperal state, scarlatina, and other 
exanthematous and febrile affections, and a host of other kindred causes. 
Finally, dropsy of either an active or passive character, may be pro- 
duced by a suspension of the cutaneous exhalent function, causing 
retention of perspirable matter ; by diseases of the heart or lungs, pro- 
ducing congestion of the venous system ; by diseases of the liver, pro- 
ducing congestion of the portal system ; and finally, by diseases of the 
kidneys, causing to be retained in the circulation the renal secretion. 

Morbid Appearances. — In cases in which the dropsy has been of a 
passive character, there is, in addition to the serous collection, a pale, 
relaxed, and perhaps dilated appearance of the capillaries and lym- 
phatic vessels. In cases in which the dropsy has been active, there is 
, not only the serous accumulation, and the dilatation of the capillary and 
lymphatic vessels, but also in cases that have followed inflammation, 
there is found the usual marks of active or passive, and generally of 
passive inflammation. And besides, the blood is apt in most cases of 
dropsy to present a watery appearance. And if the dropsy has been 
the result of some local disease of the brain, heart, liver or kidneys, 
there will be found the marks of such disease, if it has been of an in- 
flammatory or organic character; and sometimes if it has been of only 
a functional character. 

Prognosis. — The prognosis in most cases of active or passive dropsy 
35 



546 DISEASES OF THE CIRCULATORY SYSTEM. 

is rather favorable, if it is not the result of, or connected with, any local 
organic disease. And especially is it so, if the remote cause can be 
removed, and the morbid condition of the system corrected upon which 
it depends. 

But in all cases of dropsy depending upon organic disease of the 
brain, lungs, heart, liver or kidneys, or upon any local or general morbid 
condition which does not admit of correction, the prognosis is unfavor- 
able so far as the ultimate result of the case is concerned. For though 
the dropsical accumulation may perhaps be removed, or nearly so, it 
generally returns, and finally remains till the patient is worn out, either 
by the morbid accumulation, or by the organic disease upon which it 
depends. 

Treatment. — The general indications in the treatment of dropsy are 
to remove the remote cause, to correct the condition of the system upon 
which the dropsical accumulation depends, and to effect a removal of the 
accumulated fluid, whether it be in the cellular tissue, or in some one or 
more of the cavities of the body. 

If the remote cause has been irregular eating, improper clothing, un- 
reasonable exposures, habits of intemperance, or any other improprieties, 
they should be sought out at once, and removed or corrected. 

Having thus removed the remote cause, the condition of the system 
upon which the dropsical accumulation immediately depends should be 
sought out and corrected if possible, at the same time that measures are 
used for the removal of the dropsical accumulation. 

If the dropsy is of a passive character, and the result of a general 
anaemic condition, tonics should be administered, along with cathartics, 
diaphoretics and diuretics. The tincture of chloride of iron is one of the 
best general tonics in such cases, the cream of tartar one of the best 
cathartics and diuretics, and cleanliness with soft flannel next the skin a 
valuable diaphoretic. 

In cases of active dropsy, with a full strong pulse, attended with local 
irritation, congestion or inflammation, general bleeding may in some 
cases be required. After general bleeding when it is required, and at 
first when it is not, a full dose of calomel or podophyllin should be ad- 
ministered in half an ounce of castor oil, and the oil repeated if neces- 
sary. 

After the first cathartic, the bowels may be kept loose by small doses 
of cream of tartar, elaterium, scammony, or gamboge. Small doses of 
tartar emetic may be given to act upon the skin. And to increase the 
renal secretion, the ajpocynum cannabinum, digitalis, squill, or some 
other diuretic should be administered. 

In cases of dropsy in whieh the brain is involved, in addition to the 
other measures, a mercurial course, followed by iodide of potassium may 
be required. In cases in which there is hepatic disease, blue pills may be 
given for a time, and then followed by taraxacum. In case the heart is 
the seat of the disease, digitalis will be indicated. And finally, if the 
kidneys are diseased, cups, hyoscyamus, and mucilages may be required, 
in addition to the general treatment indicated in the case. 

Drinks should be allowed in limited quantities, as the dropsical patient 
is apt to be tormented with thirst. As a general rule, if the patient 
drinks tea, the black tea only should be allowed, 



ANASARCA. 547 

In passive cases of dropsy, a good nourishing diet should be allowed 
to be taken with regularity. But in active cases, plain, digestible, and 
very moderately stimulating food should be prescribed, but of this a rea- 
sonable quantity should be allowed. 

After the dropsical accumulation is entirely removed, care should be 
taken to correct the general and local conditions of the system, if it has 
not been fully done, as far as is possible, and then by care and prudence 
in every respect, there may be no return of the disease. 

SECTION XXII.— ANASARCA. 

By anasarca, from ava, "through," and crapf;, "the flesh," is here meant 
dropsical accumulation in the areolar or cellular tissue of the external 
portions of the body, if the collection or effusion takes place to any con- 
siderable extent, otherwise it might be more properly called oedema. 

Anasarca like other varieties of dropsy may be either active ox passive. 

Active cases are frequently attended with febrile excitement, and may 
be the result of sudden suppression of the perspiration, of the renal secre- 
tion, or of inflammation of the lungs, producing congestion of the venous 
and capillary system, or it may follow scarlatina. 

Passive cases of anasarca may occur from any cause, or train of causes, 
that renders the blood weak, and the tissues of the body relaxed. Fi- 
nally, anasarca either active or passive may occur from a variety of local 
organic or functional derangements, as of the skin, lungs, heart, liver or 
kidneys. 

Symptoms. — In cases of active anasarca there may be a hard, full and 
frequent pulse, or only a slightly increased action of the circulatory 
system. The countenance may be nearly natural or even flushed, though 
it is apt to assume a palish appearance. But in cases of passive ana- 
sarca the countenance is pale, the pulse weak and feeble, the extremities 
cold, and there is a general anaemic and debilitated condition of the system. 

In most cases of anasarca, the swelling commences in the feet and 
limbs, and then gradually extends over the whole body, to a greater or 
less extent. But in certain active cases, and especially in that which 
occurs from pneumonia, the anasarcous swelling is observed, first in the 
face, and then gradually extends downwards upon the trunk of the body, 
and finally to the extremities. 

The swelling from anasarca may be distinguished from all others, by 
its pale appearance, and by its pitting on pressure. 

Causes. — The most frequent causes of anasarca are suppression of the 
perspiration from cold, especially after scarlatina, inflammation of the 
lungs, or other internal organs, repelled cutaneous eruptions, disease of 
the heart, liver and kidneys, a general anaemic condition with relaxation 
of the tissues and debility, and various other local and general organic 
or functional affections. 

Prognosis. — The prognosis in idiopathic anasarca, or those cases in 
which it is not dependent upon or connected with any local organic 
disease, is rather favorable, if the remote cause can be ascertained and 
removed, and the case be subjected to proper treatment. 

But in cases of anasarca that are symptomatic of organic disease of 



548 DISEASES OF THE CIRCULATORY SYSTEM. 

the lungs, heart, liver, kidneys, or any other internal organ, the prog- 
nosis is decidedly unfavorable, so far as the final issue of the case is 
concerned. For if the effusion be removed in such cases it generally 
returns, and finally destroys the patient, unless he is sooner cut down by 
the organic disease upon which it depends. 

Treatment. — In active anasarca, if the pulse is full and strong, gene- 
ral bleeding may occasionally be required, and cups may be indicated in 
case there is any marked congestion, irritation, or inflammation of the 
kidneys, lungs, or any other part. 

After bleeding, when it is indicated, and at first when it is not, a full 
dose of calomel or podophyllin should be administered, and followed, in 
five or six hours, by half an ounce of the sulphate of magnesia, if neces- 
sary. And, if the case is urgent, two grains of calomel may be con- 
tinued, every four hours, till several closes have been administered ; to 
act gently upon the liver, and to stimulate the absorbent lymphatic ves- 
sels to increased activity. 

To promote perspiration, one-fourth of a grain of tartar emetic may 
be given, every two hours, at first, and later, every four or six hours. 
And to keep up a watery discharge from the bowels, as well as to stimu- 
late the kidneys to activity, one drachm of the bi-tartrate of potassa may 
be given, in solution, every six hours. But to act more especially upon 
the kidneys, ten drops each of the tincture of squill and tincture of 
digitalis should be given, alternating with the cream of tartar, every six 
hours. 

This treatment should be continued, modified to suit the case, till the 
anasarca is removed, or it assumes a passive character ; which unhappy 
continuation of the disease, I think, need rarely occur. 

If, however, the case does pass on, and become passive, and in all 
cases of anasarca that have been so from the first, it should be remem- 
bered that the disease is one of debility, and diligent inquiry should be 
made whether the dropsy may not be symptomatic of some local affec- 
tion of the lungs, heart, liver, or kidneys. If the dropsy is found to be 
symptomatic of a mere functional derangement of one or more of these 
organs, that functional derangement should be corrected by proper reme- 
dial measures. If, however, the local affection is organic, palliative 
measures should be used to correct, as far as possible, the functions of 
the diseased organ. 

In all cases of passive anasarca, to restore the blood, a good nourish- 
ing diet should be allowed, and, in addition, ten drop doses of the tinc- 
ture of chloride of iron may be given, three times per day, after eating. 
To stimulate the lymphatic system, liver, kidneys, and glands generally, 
five grain doses of the iodide of potassium may be given, three times per 
day, before eating. And finally, to secure a healthy action of the skin, 
it should be kept clean, and the patient should wear flannel ; and, if able, 
should take exerciser in the open air. 

SECTION XXIII.— ASCITES. 

By ascites, from aoxoj, "a bottle" I mean here a collection of serous 
fluid in the abdomen, and especially in the peritoneum, and shall only 



ASCITES. 549 

give ovarian dropsy a passing notice, as we proceed ; as it is intimately 
connected with this subject. 

Ascites may be the result of obstruction to the portal circulation, of 
disease of the liver, or it may follow inflammation of the peritoneum, or 
finally, it may occur from an ansemic state, with a general debiltated 
and relaxed condition of the system, and especially of the peritoneum 
and abdominal viscera. 

Symptoms. — Generally after an indefinite period of ill health, with 
indifferent appetite, irregular bowels, pain in the right hypochondrium, 
cold extremities, and general nervous irritability, the more immediate 
symptoms of ascites make their appearance. 

In most cases, the skin becomes dry, the urine scanty, and sometimes 
a slight uneasiness is felt in the bowels, especially if the patient lies on 
the back with the limbs extended. As these symptoms continue, a slight 
fullness is observed in the lower part of the abdomen, which disappears 
as the recumbent posture is assumed. This fullness increases if the 
disease passes on, till at last the whole abdomen becomes distended, so 
that the patient, if a female, has an appearance like that of the last 
stages of pregnancy. 

In one case of ascites, in a young lady that came under my care, the 
distension of the abdomen was so great, that the pressure on the lungs 
rendered respiration extremely difficult, and evidently interrupted very 
considerably, the pulmonary circulation. The heart, too, appeared pushed 
up, the pulse was exceedingly irregular, and the least attempt to assume 
the recumbent posture, was followed by symptoms of immediate suffoca- 
tion. This was a case of passive dropsy attended with great debility, 
as the disease had been progressing for about one year, being compli- 
cated with anasarca, and having originated in protracted functional 
derangement of the digestive organs, brought on by irregular eating, or 
taking food between meals. 

Generally, however, the abdominal distension is not so great, the 
patient being able to rest in the recumbent posture, and in some cases 
the pressure of the abdominal parietes appears to suspend the abdominal 
effusion, so that it remains nearly the same for several weeks or even 
months. In such cases, however, unless there is considerable general 
improvement in the case, there is apt to be the supervention of anasarca. 

In ovarian dropsy, which says Professor Watson,* " consists in the 
collection of the fluid in one or more of the cells within the ovary, or in 
a serous cyst connected with the uterine appendages ;" the fullness is 
first noticed in the form of a tumor in the iliac fossa of one side. This 
tumor goes on increasing, more or less rapidly, its appearance being but 
slightly affected by position, till in some cases it completely fills the ab- 
domen ; its fluid contents being colorless, brown, milky or turbid ; and 
in one case that I examined, of the multilocular variety, the fluid was 
slimy and gelatinous. 

Ovarian dropsy generally progresses slowly, and is usually attended 
in its early stages with no very marked disturbance of the general health. 
But in some cases it passes on rapidly, being attended with menstrual 
irregularities, and unless relieved, leads on to a fatal termination. 

* Watson's Practice of Physic, p. 834. 



550 DISEASES OF THE CIRCULATORY SYSTEM. 

Diagnosis. — Ascites may be -distinguished from ovarian dropsy by 
careful attention to the manner of its appearance and development. 
For, as we have seen, ascites begins by a slight fullness of the lower 
part of the abdomen, which disappears as the patient assumes the re- 
cumbent posture ; while ovarian dropsy always begins in a tumor in one 
side of the lower part of the abdomen, and is not particularly affected 
by the position of the patient. And besides, though ovarian dropsy if 
it continues, may, as we have seen, fill and distend the whole abdomen ; 
it proceeds to this stage generally much more slowly than ascites, which 
fact affords another important diagnostic difference. 

To distinguish ascites from tympanitis, percussion should be made over 
the abdomen ; when if the abdomen contains water, a dull sound will be 
elicited, but if it contains gas only, the sound will be tympanitic. But 
to render the diagnosis clear, in cases in which the abdomen contains a 
moderate amount of fluid, with more or less gas, the patient should be 
laid on the back and palpation resorted to by laying the flat hand on 
one side of the abdomen, and then tapping gently the opposite side. If 
the abdomen contains water, an impulse, caused by a wave of the fluid, 
will be distinctly felt by the hand that lays flat upon the abdomen. 

To distinguish ascites from pregnancy, is sometimes a little difiicult. 
A few years since a married lady was brought to me, from an adjoining 
county, by her husband, who expressed a great concern on account of an 
obstinate dropsy of the bowels, with which his wife was supposed to be 
suffering. The case from his account, "rather grew worse," and he was 
anxious that I should take charge of her case. 

I inquired in relation to the possibility of pregnancy, but was assured 
that such could not be the case, as the disease had been going on more 
than a year ; and besides, there never had been felt the least motion. 

Not satisfied, however, with these assurances, I had her lay flat upon 
her back, being stript so that only one linen covered the abdomen. I 
then laid my ear carefully upon the abdomen, and heard distinctly the 
sounds of the foetal heart, which I distinguished from the mother's by 
their greater frequency. I heard also distinctly the placental souflet, or 
sound produced by the passage of the blood through the placenta and 
umbilical cord. 

I informed the lady and her husband that she was pregnant, and 
advised the immediate suspension of all remedies, which being readily 
acquiesced in, the patient went home and in due time was delivered of 
a fine healthy baby. 

It should be borne in mind then, that the sound of the foetal heart, 
and the placental soaflet, when distinct, constitutes a positive diagnostic 
symptom between ascites and pregnancy. Other symptoms and circum- 
stances, however, may be taken into the account, in case there remains 
a shadow of doubt. 

Causes. — It is probable that the most frequent causes of ascites are 
obstruction to the portal circulation, congestion, irritation or inflamma- 
tion of the peritoneum, and organic or functional diseases of the heart, 
liver or kidneys. Ascites may be produced, however, by indigestion, 
from irregular eating, by intoxicating liquors, or in fact by any cause, 
or train of causes which produce an anaemic state, with a relaxed condi- 



ASCITES. 551 

tion of the tissues of the body, affecting especially the capillaries of the 
peritoneum and abdominal viscera. 

Ovarian dropsy may arise from causes similar to those producing 
ascites. But I believe it is more frequently connected with, and pro- 
duced by menstrual irregularities, or some organic or functional disease, 
or derangement of the womb or genital organs. 

Prognosis. — The prognosis in ascites disconnected with organic disease 
is rather favorable, if the case be subjected to proper treatment in season, 
most such cases that have fallen under my observation, having perma- 
nently recovered. In cases of ascites, however, which depend upon, or 
are connected with organic disease of the heart, liver, kidneys or lungs, 
and in ovarian dropsy, the prognosis is unfavorable, so far as the ulti- 
mate result of the case is concerned, recoveries being an exception to 
the rule. 

Treatment. — The first step in the treatment of ascites is to seek out 
and if possible remove the remote cause, whether it be irregular eating, 
intoxicating liquors, or any other imprudence. This, alone, if the patient 
be made to conform rigidly to the laws of health, in every respect, will 
sometimes arrest the progress of the disease, at least. 

If now the liver is in a state of congestion or chronic inflammation, 
cups may be applied, and a few ounces of blood taken, and, if neces- 
sary, a blister applied to the right hypochondrium, or right side of the 
spine. 

If the kidneys show signs of inflammation, cups should be applied on 
each side of the spine, in the inferior dorsal and lumbar regions, and a 
few ounces of blood taken. 

If there is evidence of inflammation of the alimentary canal, or of 
the peritoneum, cups, and then leeches or blisters, may be applied to the 
epigastrium, and, if necessary, to the abdomen ; and if there are febrile 
symptoms, a full dose of calomel or podophyllin should be administered. 

After thus subduing the local congestion, irritation or inflammation, 
as well as general febrile excitement, if they exist, and in all cases in 
which these complications are not discoverable, measures should be taken 
for the removal of the accumulated fluid. 

To keep the bowels loose, and to establish a drain by the bowels for 
the accumulated water, a pill of gamboge, scammony and rhubarb, of 
each one grain, may be given each day after dinner. To act upon the 
lymphatic and glandular system, and thus afford another drain, the 
iodide of potassium should be given in five grain doses, three times per 
day, and continued. Finally, to establish a drain by the kidneys, the 
officinal infusion of digitalis, made by macerating a drachm of the dried 
leaves, in half a pint of boiling water, in a covered dish, for two hours, 
should be given in table-spoonful doses, three times per day,* with twenty 
drops of the tincture of squills, if the case is urgent. 

The skin should be kept clean and warm, and strong iodine ointment 
should be rubbed over the whole abdomen twice per day. The abdomen 
should be kept swathed with a firm flannel cloth, for the purpose of pro- 
moting perspiration, and also of contracting down the abdominal parietes, 
as the water is drained off. 

* A fluid ounce of tincture of cinnamon is to be added. See Dispensatory. 



552 DISEASES OF THE CIRCULATORY SYSTEM. 

The abdominal fluid has generally been removed in this way, in cases 
under my care, within two weeks, and, in some cases, much sooner than 
that. As soon as the water is removed, the digitalis should be discon- 
tinued, and the tincture of chloride of iron given in ten drop doses in- 
stead, as a tonic and diuretic, and this should be continued with a good 
nourishing diet, till the health and tone of the system is restored. 

In cases of ovarian dropsy, the general condition of the patient should 
be kept the best possible under the circumstances; and should inflamma- 
tion arise in the tumor, cups, leeches, or blisters, followed by iodine 
ointment may be applied over its seat for a time. Finally, should the 
tumor become very large, so as to endanger life, I believe, if the patient 
prefers the risk, that ovariotomy should be resorted to, especially if tap- 
ping, iodine injections, &c. have been resorted to, as is often the case, in 
vain. 

I am the more disposed to favor ovariotomy as a last resort, in cases 
that must, without the operation, soon terminate fatally, from observa- 
tions made in this vicinity within the past few years. My friend, Dr. 
H. A. Potter, an eminent surgeon of this village, to whom reference has 
already been made in the early part of this work,* has removed several 
ovarian tumors ; in two cases of which the result of the operation has 
been entirely satisfactory. One of these operations I witnessed, and I 
am confident that without it the patient must soon have perished. Both 
these ladies are now, I believe, in the enjoyment of good health. 

SECTION XXIV.— HYDKOTHOKAX. 

By hydrothorax, from v5wp ? "water," and flwpal, " the chest," I mean 
here, more especially, dropsy of the pleura, but shall also notice, as we 
pass, pulmonary oedema, or dropsy of the lungs, as the two conditions 
often exist simultaneously. 

Hydrothorax may be, like other varieties of dropsy, either active or 
passive; in the one case being the result of congestion, irritation, or in- 
flammation of the pleura, while in the other it is the result of an anaemic 
condition, with a watery state of the blood, and a relaxed condition of 
the tissues of the body. 

Hydrothorax is very apt to be connected with organic disease of the 
heart, and it often follows pleuritic inflammation. It may also be com- 
plicated with, or independent of pulmonary oedema. 

Symptoms. — At first, when the pleuritic effusion is small, only a slight 
uneasiness is felt in the lower part of the chest, referred to the sternal 
region. As the effusion continues, however, the patient suffers a slight 
uneasiness in assuming the recumbent posture; generally a cough and 
difficulty of breathing being the result. As the accumulation increases, 
additional pillows are used by the patient, till at last he is unable to lie 
down at all. The dyspnoea is considerable, and at times, from slight 
exercise or mental excitement, it becomes very distressing. 

Generally, about this stage, the face becomes oedematous, the cheeks 
assume a purple hue, the lips become livid, and at times almost black, 
and the patient is liable, though he sleep in the sitting posture, to sud- 

* See article Erysipelas. 



HYDROTHORAX. 553 

den starting, followed by dyspnoea, with more or less mental excitement. 
During the continuance of the disease, the skin is apt to be dry, the 
urine scanty, the bowels constipated, and there is considerable thirst. 

If percussion be made on the chest, while the patient is in the sitting 
posture, a dull sound is produced, as high as the accumulated water ex- 
tends. Above this point, however, the resonance is nearly or quite 
natural. 

Auscultation detects an absence of the natural respiratory murmur, 
and in its place, in many cases, the tubular breathing, caused by the 
passage of air along the larger bronchial tubes, the air-cells and smaller 
bronchial tubes being closed up by the pressure of the pleuritic effusion. 

The sound of the voice too, at this stage of the disease, is generally 
increased, constituting the peculiar bleating sound called segophony. 
This sound, however, as well as the tubular breathing, gradually disap- 
pears as the amount and pressure of the fluid increase, till they are 
audible only in the interscapular region. 

Succussion, if carefully performed, may aid in detecting a moderate 
amount of pleuritic effusion, by producing a sound similar to that caused 
by tipping a cask, containing a small amount of water, especially if the 
pleura also contains air or a gas. 

Inspection, if the accumulation be considerable, detects a fullness of 
the affected side, and in some cases a bulging at the intercostal spaces. 
This may be confirmed, and its extent ascertained, by mensuration with 
a tape, as suggested in a preceding section. 

If the effusion has taken place in only one side of the chest, the pa- 
tient lies on the affected side, but if in both, the patient has the head 
very much elevated, or sleeps in the sitting posture. 

In cases of oedema of the lungs, the fluid may occupy the air-cells, or 
the extra-vesicular cellular tissue, or what is more common, the effusion 
may take place in both portions. The disease is attended with dyspnoea, 
more or less cough, and a copious expectoration of a thin, colorless, and 
sometimes frothy matter or fluid. 

There is slight dullness on percussion, and a diminution of the respi- 
ratory murmur, and especially in the posterior and lower, or most depend- 
ing portion of the chest. There is generally a subcrepitant and mucous 
rale or rattle, caused by the presence of the fluid in the air-cells and 
bronchial tubes. 

(Edema of the lungs is often connected with pleuritic effusion, in 
which case there is a combination of the symptoms peculiar to each dis- 
ease, which fact must always be borne in mind, in the examination of 
patients with hydrothorax. 

Diagnosis. — Hydrothorax may generally be distinguished from other 
affections by the dyspnoea, and slight cough, by the sudden starting 
during sleep, by the gradual inability to assume the recumbent posture, 
the oedema of the face, and finally by the dullness on percussion, toge- 
ther with the absence of the natural respiratory murmur, and presence 
of tubular breathing, and the peculiar bleating sound of the voice or 
oegophony. 

(Edema of the lungs, when it exists as a distinct disease, may be dis- 
tinguished from pleural dropsy by the dullness and diminution of the 



554 DISEASES OF THE CIRCULATORY SYSTEM. 

respiratory murmur being less marked. From pneumonia it differs in 
wanting the febrile symptoms, as well as the rusty or bloody appearance 
of the matter expectorated. Finally, when hydrothorax consists, as is 
often the case, of a pleuritic effusion, and also of pulmonary oedema, the 
real condition must be ascertained by all the symptoms and circumstances 
of the case. 

Causes. — The causes of hydrothorax, are organic diseases of the heart, 
congestion, irritation or inflammation of the pleura, organic or functional 
disease of an the liver or kidneys, gastro-enteritis, or indigestion, sup- 
pressed perspiration, and an anasmic state, with a watery condition of the 
blood, and relaxation of the tissues of the body. But among these causes, 
it is probable that organic diseases of the heart, congestion, irritation, or 
inflammation of the pleura, and a general anaemic condition are by far the 
most frequent. 

Prognosis. — The prognosis in hydrothorax is rather favorable, if it 
can receive proper treatment in season, and in case there is no organic 
disease upon which it depends. But in neglected cases, and especially 
in such as depend upon, or are connected with serious organic disease, 
the prognosis is unfavorable so far as the final result of the case is con- 
cerned, and the case may pass on rapidly to a fatal termination. 

Treatment. — The treatment for hydrothorax divides itself into that 
which is proper for active and that which is indicated for passive cases, 
taking into account of course, the complications which are liable to exist 
or arise in either variety or form of the disease. 

In active cases, attended with or preceded by congestion, irritation, or 
inflammation of the pleura, whether complicated or not with oedema of 
the lungs, a full dose of calomel should be given in castor oil, and then 
alterative doses of two grains administered every four hours, for one or 
two days, to stimulate the absorbents. Tartar emetic should be admin- 
istered in one-fourth of a grain doses, at the same time, alternating with 
the calomel, and this should be continued after suspending the alterative, 
if there is any febrile excitement or the skin remains dry. 

Warm pediluvia should be resorted to, a moderate amount of warm 
sage tea allowed, and if necessary, cups, wet or dry, or blisters may be 
applied to the chest. 

After the febrile excitement is subdued, if any had existed, and on 
suspending the mercurial, the tartar emetic may be continued with five 
grain doses of the iodide of potassium every six hours, to act on the ab- 
sorbent vessels and glandular system. 

If the case is urgent, one sixth of a grain of elaterium may be given 
every six hours, for a time, alternating with the iodide of potassium, and 
when it has been continued as long as required, or as is prudent, it should 
be suspended, and a drachm of the bi-tartrate of potassa given in solu- 
tion instead. This, alternating with the iodide of potassium, should be 
continued till a cure is effected. 

In one desperate case of pleuritic distension, complicated with pulmo- 
nary oedema and geneal anasarca, in which the patient appeared in 
danger of perishing from suffocation every moment ; the water was nearly 
all drained off by the bowels by the elaterium, administered as suggested 
above, in forty-eight hours. On my asking him the second day, how the 
medicine operated, he replied that it "jerked him." 






HYDROPERICARDIUM. 555 

In passive cases of hydrothorax, with or "without pulmonary oedema, 
two or three blue pills may be given at first, and followed by half an 
ounce of the sulphate of magnesia ; after which the bowels may be kept 
loose by a hydragogue pill, of gamboge, scammony and rhubarb, of each 
a grain ; taken after dinner each day. 

After the operation of the first cathartic, the iodide of potassium 
should be given in ten grain doses three times per day, before eating, 
well diluted. If there is organic disease of the heart, twenty drops of 
the tincture of digitalis, or ten drops of the fluid extract, may be given 
four times per day, to which, if the kidneys are torpid, twenty drops of 
tincture of squill may be added. 

The iodide of potassium should be continued, and the hydrogogue pill 
till the dropsy is removed, when it should be discontinued, and ten drop 
doses of the tincture of chloride of iron given instead, and continued till 
the blood is restored, as far as may be. 

In active cases the diet should be plain, and unstimulating ; but in all 
passive cases, a good nourishing diet should be allowed. 

SECTION XXY.— HYDEOPERICARDIUM. 

By hydropericardium, from 'u5wp, " water," and pericardium, I mean 
here an abnormal collection of water or serum in the pericardium, or 
dropsy of the heart. 

To understand this subject, it is necessary to remember the position 
of the heart, in the separation of the mediastinum above the central 
aponeurosis of the diaphragm. And also, that the inner or serous mem- 
brane of the pericardium, after lining, the inner surface of the fibrous 
layer is reflected over the heart, which it entirely covers ; making it like 
other serous membranes, a shut sac. The pericardium thus constituted, 
with its external fibrous layer, is supplied with arteries, veins and lym- 
phatics ; and in a state of health, contains in its cavity a small amount of 
fluid, which facilitates the heart's movements. 

It is only then, when this serum in the pericardium accumulates in 
excess, that it becomes a disease constituting hydropericardium, or dropsy 
of the heart. This abnormal accumulation of serum in the pericardium 
may vary in quantity from half a pint to several quarts, and it may be 
the result of congestion, irritation, or inflammation of the pericardium, 
constituting the active form of the disease. Or it may be of a strictly 
passive character, depending upon a watery state of the blood, and a 
relaxed condition of the tissues, and perhaps associated with some 
organic disease of the heart, lungs, liver, kidneys or alimentary canal. 

It is probable that serous effusion into the pericardium becomes ab- 
normal, producing derangement of the heart's actions, of the circulation, 
and of the respiration, after it has reached six or eight ounces. As it 
goes on accumulating above this amount, a train of distressing symptoms 
are developed, which we will now proceed to consider. 

Symptoms. — The early symptoms of hydropericardium, while the ac- 
cumulation is yet small, are generally quite obscure, especially if it is 
complicated with hydrothorax, or some organic disease of the heart or 
lungs. .But as the accumulation increases, there is a feeling of unea.si- 



556 DISEASES OF THE CIRCULATORY SYSTEM. 

ness or pressure in the region of the heart. There is apt to be also a 
slight cough, the respiration is irregular, or uneasy, occasional fits of 
faintness occur, and along with great oppression in the precordial re- 
gion, there is excessive nervous irritability. 

The patient is disinclined to lie down, and generally sits with the head 
and chest leaning forwards, the pulse is small, irregular and feeble, the 
face and lips are purple or livid, the appetite is irregular, and the sleep 
disturbed. At times the patient may appear quite smart, but exacerba- 
tions occur, during which most of the unpleasant symptoms are greatly 
aggravated. At such times, the anxiety and restlessness become exces- 
sive, and delirium, or the most painful irritability is liable to attend. 

Towards the termination of fatal cases, the patient is apt to become 
stupid, the action of the heart is weak and very irregular, the extremities 
become cold, the surface of the body is covered with a clammy perspira- 
tion, and death at least occurs from a weakened and obstructed circula- 
tion, and perhaps from the direct pressure of the pericardial effusion sus- 
pending the heart's functions. 

Percussion in the early stage of the disease detects but little if any 
dullness. But as the pericardial effusion increases, there is a marked 
dullness on percussion. It is noticed first on the left side of the lower 
portion of the sternum, and gradually extends upwards. When, how- 
ever, the pericardium becomes largely distended, the dullness is very re- 
markable, and extends in every direction, but especially transversely and 
inferiorly. 

The impulse of the heart is lessened, and its rhythm becomes greatly 
disturbed, as the accumulation increases, varying from the treble beat, to 
an utter confusion in the succession of the heart's sounds. 

Auscultation detects also a decided diminution or decrease in the 
sounds of the heart. In most cases that have fallen under my observa- 
tion, the sounds have become scarcely audible, and have appeared as if 
they were made at a great distance from the ear. 

Such I believe are the ordinary symptoms of dropsy of the heart. 
But it must be remembered that this affection may be complicated with 
organic disease of the heart, lungs, &c, the symptoms of which must be 
taken into account in examining such cases. 

Diagnosis. — A correct diagnosis may generally be formed in hydroperi- 
cardium by careful attention to all the symptoms which are developed. 
But the symptoms which more particularly point out this affection, are 
the feeling of oppression in the region of the heart, a disposition on the 
part of the patient to sit up or lean forward to rest, instead of assuming 
the recumbent posture, a lessened impulse, and decrease of the sounds of 
the heart, with a disturbed rhythm, and finally dullness on percussion 
over an extended space or surface in the precordial region. 

Morbid Appearances. — The appearances on dissection, are not very 
marked, aside from the serum in the pericardium. Sometimes, however, 
in active cases, the pericardium exhibits traces of inflammation, there 
being increased vascularity, and ulceration of its lining serous mem- 
brane. The quantity of serum found in the pericardium, varies, as I 
have already suggested, from half a pint, to several pints, or even quarts. 

Prognosis. — Complicated as this affection, very generally is, with 



HYDROCEPHALUS. 557 

organic disease of the heart, lungs, or some other important vital organ 
or part, or else associated with great general debility; the prognosis is 
generally unfavorable. It is probable, however, that cases uncomplicated 
with serious organic diseases, sometimes recover, under judicious treat- 
ment. 

Treatment. — In cases of lrydropericardium of an active character, de- 
pending upon congestion, irritation, or inflammation of the pericardium ; 
cathartics, cups, blisters, &c, should be resorted to, with a slight mercu- 
rial course, till the pericardial irritation, or inflammation is subdued. 
Having accomplished this, and also corrected any general or local in- 
flammatory, or other complication, remedies should be persevered in, for 
the removal of the pericardial effusion. For this purpose, twenty drops 
each of the tincture of squill, and tincture of digitalis, to act upon the 
kidneys ; with eight grains of the iodide of potassium, to affect the 
lymphatic and glandular system, should be given every six hours. 

Alternating with this, to establish a drain by the bowels, a drachm of 
the bitortrate of potassa, should be given in solution, and this treatment 
should be continued, keeping the skin clean and warm, till the pericardial 
accumulation is removed. 

In passive cases of the disease, the patient should take a mercurial 
cathartic at first, and then the iodide of potassium, with the squill and 
digitalis, as suggested above, and instead of the cream of tartar for the 
bowels, a pill of gamboge, scammony, and rhubarb, of each, a grain 
may be given, after dinner, each day. 

SECTION XXVI.— I1YDKOCEPHALUS. 

By hydrocephalus, from uSwp, "water," and see^aju?, "the head," I 
mean here, water in the head or dropsy of the brain; whether the effusion 
occupies the ventricles of the brain, or the cavity of the arachnoid 
membrane. 

Hydrocephalus, like other varieties of dropsy, may be either active or 
passive. If active, it is generally the result of congestion, irritation, or 
inflammation of the arachnoid membrane, or else of the serous mem- 
brane, which lines the ventricles. 

If passive, it depends, like other varieties of passive dropsy, upon a 
hereditary or acquired depravity of the system, in which there is a weak 
or watery state of the blood, and a debilitated and relaxed condition of 
the tissues of the body. 

Hydrocephalus is confined to no age, but it generally occurs during 
infancy or childhood, active cases, passing on generally in a few days 
or weeks to a fatal termination, while passive cases may be congenital, 
and of protracted duration, passing on sometimes for months, or even 
years. 

Hydrocephalus is attended with a train of distressing symptoms, some 
of which are peculiar to the active, while others are peculiar to the passive 
form of the disease. We will therefore proceed first to consider the symp- 
toms of active cases, and then examine so much of the symptoms of 
cases, as are peculiar to that form of the disease. 

Symptoms. — The active form of this disease, as we have already seen, 



558 DISEASES OF THE CIRCULATORY SYSTEM. 

may be the result of congestion, irritation or inflammation of the arach- 
noid membrane, or else of the serous membrane which lines the ventricles, 
or what is probably more common, of both. In cases that are inflam- 
matory, there are developed, before the effusion takes place, all the 
symptoms peculiar to arachnitis, such as pain in the head, intolerance 
of light, irritability, nausea and vomiting, with febrile excitement. 

In active cases in which there is only irritation or active congestion of 
the brain and its meninges, the effusion is preceded by an irritable 
peevish, or fretful state of the little patient. The appetite is variable, 
the bowels are constipated, there is intolerence of light, and nausea with 
vomiting from very slight causes. The urine becomes scanty, there is 
pain in the head, referred often to the temples, the pupils contract, 
there is starting during sleep, slight febrile symptoms arise towards 
evening, and the child often screams suddenly, as if suffering from acute 
pain. 

After these symptoms have gone on progressing for a few days, or 
sometimes weeks, effusion takes place, either into the cavity of the arach- 
noid membrane, or else into the ventricles of the brain, or into both. 
As this occurs, it relieves the congested cephalic meninges for the time, 
so that the pain in the head subsides, the pupils become natural, light is 
tolerated, the nervous irritability is less, and to a superficial observer the 
patient may appear decidedly better. 

But this temporary abatement of the symptoms, caused by the effusion 
is followed by the real symptoms of hydrocephalus, for as the effusion 
increases, the ventricles or the arachnoidal membrane, or both become 
distended and the pressure upon the brain develops a new and most dis- 
tressing train of symptoms. 

The patient gradually becomes stupid, the pupils dilate, there is 
paralysis of an arm or limb, the thumb of one hand is brought firmly 
into the palm, and the hand carried above the head, and there may be 
loss of sight and hearing. Finally terrible convulsions of the voluntary 
muscles occur, followed by coma, from which the patient can be but par- 
tially aroused, if at all, and in this state the patient may linger, with 
occasional convulsions, for several days, when either in a state of pro- 
found coma, or terrible convulsions he expires. 

Such, according to my observation, are the symptoms of hydrocepha- 
lus, as it occurs in the active form, from inflammation, irritation, or 
active congestion of the brain or its meninges, and especially of the 
arachnoid, and lining serous membrane of the ventricles. We will now 
proceed to the consideration of the passive form of hydrocephalus, or 
that which is the result of hereditary or acquired depraved condition of 
the system, the effusion being the direct result of passive cephalic con- 
gestion, as well as of a watery state of the blood, and a relaxed condition 
of the tissues. 

This form of hydrocephalus may be congenital; or it may occur in 
early infancy or childhood ; and possibly during any subsequent period 
of life. 

The symptoms in congenital cases, as well as in those occurring in 
early infancy, are very marked, as the head is generally more or less 
enlarged, with the sutures gaping, or the bones spread apart ; and some- 



HYDROCEPHALUS. 559 

times tumors are projecting from the open sutures. Or the head may 
he illy shaped, being more prominent on one side than the other, or in 
some particular part. 

I remember to have seen a case in which the head of a child, only a 
few months old, was not only deformed, but was nearly the size of an 
adult head. 

In those cases that occur later in childhood, and at adult age, there is 
generally no visible enlargement of the head, as the bones have become 
too firm to yield to the internal pressure. Such cases generally termi- 
nate fatally within a few weeks ; but sometimes the patient lives on in 
this condition for several years, laboring under more or less physical 
and mental derangement. 

Sometimes the pressure upon the brain, caused by an accumulation of 
serum in the ventricles, or in the cavity of the arachnoid membrane, is 
borne with comparative slight impairment of the mental faculties. But 
ultimately the patient, in most cases, becomes emaciated, stupid, and in- 
different ; the countenance is without expression; the gait is unsteady; 
convulsions and coma supervene ; and the patient finally dies, either 
comatose or in convulsions. 

Such, I believe, are the ordinary symptoms of passive hydrocephalus ; 
liable, of course, to variations, depending upon the general condition of 
the patient, and the amount of the cephalic effusion. 

Anatomical Characters. — In cases in which the dropsy has been of an 
active character, the arachnoid membrane, or the lining membrane of 
the ventricles, show signs of having been inflamed, or of active conges- 
tion. The ventricles contain more or less colorless serum, in most cases ; 
but if the fluid is found mainly in the cavity of the arachnoid, it may be 
of a bloody serous character. 

In cases that have been of a passive character, a large amount of fluid 
is generally found in the ventricles, which are very much enlarged, and 
sometimes thrown into one extended cavity, the cerebral substance form- 
ing their parietes being either of a natural consistence, or else hardened 
or softened ; or the fluid may occupy the cavity of the arachnoid mem- 
brane, in which case the brain is compressed into the bottom of the cra- 
nial cavity. Or, as sometimes happens, an opening is made in the com- 
missures of the brain, and the cavity of the ventricles and that of the 
arachnoid are thrown into one. 

The quantity of liquid found in hydrocephalus, varies from a few ounces 
to several pounds, and it generally contains more or less albumen, and a 
small proportion of various saline substances. 

Diagnosis. — In cases of active hydrocephalus, it may be at first diffi- 
cult, or even impossible, to be certain that effusion has taken place. 

If, however, after a more or less protracted stage of irritability, and 
perhaps febrile excitement, &c, the symptoms subside, and after an in- 
definite period, varying from a few hours to several days, a new train of 
symptoms arise, such as stupor, convulsions, paralysis, &c, it may be 
regarded as nearly certain that effusion has taken place, either into the 
ventricles or into the cavity of the arachnoid membrane. 

Passive cases of hydrocephalus, if congenital, or occurring during early 
infancy, may generally be distinguished by the enlargement of the head, 



560 DISEASES OF THE CIRCULATORY SYSTEM. 

together with the attendant symptoms. And if later in life, there comes 
on, in connection with great debility, and especially a scrofulous condi- 
tion, evidence of continued internal pressure of the brain, with marked 
physical, and more or less intellectual disturbance ; and the patient is 
affected with strabismus, loss of speech, paralysis, &c, the case may be 
regarded as passive hydrocephalus. 

Causes. — Active cases of hydrocephalus may be produced by any cause 
or train of causes that favor congestion, irritation, or inflammation of the 
brain and its meninges, such as constipation of the bowels, intestinal 
worms, direct injuries of the brain, &c. 

Passive hydrocephalus is generally hereditary, depending upon a scro- 
fulous or tuberculous depraved inherited constitution ; or else, if it occur 
later in life, it is the result of various abuses of the system, such as mas- 
turbation, sexual excesses, the use of tobacco, drunkenness, &c. 

Prognosis. — The prognosis in hydrocephalus is decidedly unfavorable, 
especially if it is the result of a scrofulous or tuberculous condition, or 
is connected with any organic lesion. If, however, it is solely dependent 
upon functional derangement, it is possible that recovery may take place, 
if the deranged function be corrected, and proper remedies be resorted 
to for the absorption of the effused fluid. 

Treatment. — In the active form of the disease, to subdue the irritation, 
congestion or inflammation upon which the effusion depends, general 
bleeding should be resorted to, if indicated ; and then a full dose of calo- 
mel in castor-oil administered. Cups, wet or dry, should be applied to 
the temples or back of the neck, and then blisters, and after the opera- 
tion of the cathartic, alterative doses of calomel should be given every 
four hours, with James's powder, till a slight mercurial impression is 
produced, when it should be suspended, and the antimonial continued, 
every six hours ; and alternating with it, full doses of the iodide of po- 
tassium should be given. This treatment should be continued, with warm 
pediluvia, blisters back of the ears and to the back of the neck ; and 
sufficient cream of tartar, morning and evening, to keep the bowels loose, 
till recovery or a fatal termination takes place. 

In passive hydrocephalus, whether occurring in early infancy or later 
in life, a cathartic of calomel or podophyllin and castor oil may be 
given at first. And unless contra-indicated, on account of a scrofulous 
or tuberculous condition, alterative or slightly cathartic doses of calomel 
may be given, morning and evening, for a few days, when it should be 
suspended, and the bowels kept loose by small doses of the bitartrate of 
potassa. 

On suspending the mercurial, if it is used, and immediately after the 
operation of the cathartic, in cases in which it is contra-indicated, the 
iodide of potassium should be administered in full doses, three times per 
day, with moderate diuretic doses of the tincture of squill. This treat- 
ment should be continued, with blisters back of the ears and to the back 
of the neck, and if necessary, small doses of the citrate of iron after 
each meal, or even cod liver oil, till the hydrocephalus is removed, or 
the case is rendered hopeless. 

The skin should be kept clean and warm, and the patient, whether 
young or old, should be allowed a reasonable amount of proper nourish- 



SCROFULA. bbl 

merit, and sufficient pure dry air, and on no account should be exposed 
to any other. Finally, if the patient appears ready to perish, a trochar 
may be introduced perpendicularly at one edge of the anterior fontanel, 
and the water drawn off, after which the head should be compressed 
firmly by adhesive straps or a bandage. 

SECTION XXVIL— SCROFULA. 

By scrofula, I mean here that peculiar morbid or deranged condition 
of the whole system of nutrition, but especially of the lymphatic system, 
and lymph itself, attended with indolent glandular tumors in the neck, 
axillae, groins, mesentery, and other parts of the body. 

Now, in order to understand this subject, it must be remembered that 
the vessels that act exclusively for the growth of the system, are the 
lacteals, which are found along the alimentary canal. The lymphatics 
in other parts of the system remove matter already deposited, a function 
which they probably hold in common with the extreme veins, and the 
venous portion of the capillaries. 

The lymphatic vessels are extremely small at their origin, and they 
exist in great numbers in the skin, mucous membranes, and in every 
part of the body, except perhaps in the substance of the brain. 

The lymphatics, like the arteries and veins, have three coats, and like 
the veins they converge to form larger trunks, as they pursue their 
course towards the large veins near the heart, into which they pour 
their fluid contents, both lymph and chyle. 

At certain points along the lacteals, and all the lymphatic vessels, 
they pass through distinct glands, the lacteals through the mesenteric, 
and the other lymphatics through the lymphatic glands in different parts 
of the body. They are, however, most numerous in the neck, axiltee, 
groins, and in the cavities of the chest and abdomen. 

The lymphatic glands, vary in size, and appear to consist of a plexus 
of minute lymphatic vessels, associated with a plexus of blood-vessels, 
encased in a capsule of areolar tissue. 

Now, the lacteals in a healthy state of the system, take up the chyle 
along the intestines, with perhaps transuded albumen, and convey it 
through the mesenteric glands, where some of its fat and albumen is 
converted into fibrin, and thence it passes to the thoracic duct, through 
which it is carried into the blood at the junction of the left subclavian 
with the left jugular vein. 

The other lymphatics, however, imbibe all the various constituents of 
the body, both fluid and solid, after their vitality have ceased, and they 
also absorb foreign substances when exposed to their mouths, as well as 
more or less albuminous matter transuded from the small blood-vessels. 

In a healthy state of the system, the lymphatics take up all the wastes 
of the system not absorbed by the extreme veins, together with more or 
less albumen which transudes from the blood, all of which is conducted 
through the lymphatic glands, where a portion of the albuminous matter 
is converted into fibrin. This being accomplished, the lymph thus fibrin- 
ized passes on, to enter the blood, either through the thoracic duct, or 
by trunks that empty directly into the large veins. 
36 



562 DISEASES OF THE CIRCULATORY SYSTEM. 

Now, it will be seen, that imperfect chyle, with derangement of the 
lacteal and other lymphatic vessels, as well as of the mesenteric and 
lymphatic glands, involves a derangement of nutrition and absorption, or 
that process in the system, by which the old tissues are removed, and new 
matter furnished to supply its place. This derangement, then, consti- 
tutes, as I believe, the scrofulous diathesis or condition, and it may be 
either hereditary or acquired — in either case, developing a train of symp- 
toms which we will now proceed to consider. 

Symptoms. — The countenance of scrofulous patients has a delicate, 
soft, flaccid aspect, with a frequent swelling or fullness of the upper lip. 
The hair is generally lightish and fair, and the eyes blue ; there is a 
proneness to catarrhal affections, and the edges of the eyelids are liable 
to become inflamed, being often red and tender. The digestive poweis 
are weak, the appetite variable, the urine deposits a whitish sediment, 
and there is a strong tendency to swelling or enlargement, with indura- 
ration of the mesenteric and other lympathic glands ; there is a ten- 
dency to excoriations behind the ears, and scaly eruptions on the head ; 
there is often an obstinate and protracted ophthalmia — the temper is irri- 
table, and the growth of the body proceeds slowly, while the mental 
powers are generally precociously developed, and often very active. 

Now all these symptoms are just what might be anticipated, from a 
deranged condition of the whole system of nutrition and absorption, 
which we have already seen constitutes scrofula. And this scrofulous 
condition, whether hereditary or acquired, may continue for several 
years, and finally pass off without terminating in any very serious local 
affection. Generally, however, the scrofulous habit increases, and at 
last, under the influence of certain exciting causes, shows itself in its 
more obvious and active form. 

In cases that pass on and progress, the mesenteric glands are very 
liable to become enlarged and indurated. The lymphatic glands along 
the neck, in the axillse, groins, or other parts of the system may become 
enlarged, and firm to the touch, in which indolent condition they often 
remain for years. Or they may pass on by degrees, into slow inflamma- 
tion which at last sometimes terminates in suppuration. When suppura- 
tion does take place, indolent ulcers are formed from which a thin puru- 
loid serum is discharged. The ulcers thus formed are slow to heal, and 
when they do, the cicatrices which are left are uneven, irregular, and 
conspicuous. 

In conjunction with the tumors or ulcerations of the neck, the eyelids 
become in some cases permanently inflamed, and there is apt to be irri- 
tation of the Schneiderian membrane, and sometimes of the mucous mem- 
brane of the bronchial tubes. As the disease advances, and the internal 
and external glandular structures become involved, the various functions 
of the body become materially deranged. 

Scaly eruptions appear on different parts of the surface, the bones 
enlarge and become carious, the cartilages ulcerate, the large joints en- 
large and suppurate, the vertebrae may become diseased, and not unfre- 
quently the bones of the nose and palate are more or less rapidly de- 
stroyed by ulceration. Finally scrofula may develop its local manifesta- 
tions in any of the soft or solid tissues of the body, but its most frequent 



SCROFULA. 563 

serious local manifestations are in tuberculous meningitis, tubercular 
phthisis, white swelling, or disease of the hip or knee joints, ophthalmia, 
and scrofulous nodes in the mesentery, lungs, liver, spleen, brain, and 
other internal or external organs or tissues of the body. 

The manifestations of the scrofulous habit seldom make their appear- 
ance very markedly before the period of dentition. And the progress of 
the disease is exceedingly various, being sometimes fully developed dur- 
ing infancy or childhood, but in other cases, not till the age of puberty, 
or even much later than that. 

Anatomical Cliaracters. — The glands early are either found simply 
enlarged, and a little firmer than in health, or else if more advanced, 
they are of a grayish color, with a granular structure, and very decidedly 
indurated. Or if still more advanced, the proper tissue of the glands 
are more or less absorbed, and tuberculous matter is found either irregu- 
larly infiltrated, or deposited in the form of distinct granulations. If 
the disease was still more advanced, abscesses may be found containing 
softened tuberculous matter, with more or less unhealthy pus. 

Diagnosis. — Scrofula may generally be distinguished from all other 
diseases by the countenance, the blue eyes, light hair, fair skin, tumid 
upper lip, &c, in its early stages. Later, by the variable appetite, 
eruptions about the ears, and on the scalp ; glandular enlargements and 
induration; and various other like symptoms. Finally, in the last stages 
of the disease, it may be distinguished by the emaciation, and general 
haggard appearance of the patient, together with whatever local mani- 
festation of the disease there may chance to be developed. And besides, 
the diagnosis may be aided, in all stages by the fact of a strong here- 
ditary predisposition to the disease. 

Causes. — This peculiar morbid or irritable and deranged condition of 
the lymphatic system, may, as we have seen, be hereditary, or it may 
be produced by a variety of causes, such as damp impure air; insufficient 
or unwholesome food ; measles, scarlatina and hooping cough ; and by 
chronic inflammation of the alimentary mucous membrane. 

The hereditary predisposition to scrofula doubtless consists in an im- 
perfection of the digestive organs ; and a peculiar or defective organiza- 
tion of the lymphatic and other lacteal vessels and their glands, in 
consequence of which, digestion, nutrition, and absorption are performed 
very imperfectly. For there is a failure either of the digestive organs, or 
of the lacteals or their glands, to furnish, take up, or prepare sufficient 
nourishment, to supply the wastes of the system. Or else an inability 
on the part of the absorbents to take up, or of their glands to properly 
change the wastes of the system. 

It is probable, however, that the hereditary predisposition to scrofula, 
consists in an imperfection of the digestive and assimilative organs ; and 
also of the absorbent lymphatic vessels and glands. That being the 
case, only slight exciting causes are capable of developing the disease. 

Change from a warm to a cold climate is peculiarly liable to develop 
scrofula in those who are predisposed ; as well as exposure to cool damp 
air, both operating probably to render torpid the lymphatic vessels, and 
irritate the lymphatic glands. Impure air probably produces scrofula 
by entering the circulation, or in part perhaps by affecting the lymphatics 



564 DISEASES OF THE CIRCULATORY SYSTEM. 

of the skin and lungs. It probably also fails to supply sufficient oxygen 
to the blood, and it may directly impair digestion, and thus cut off the 
supply of nourishment. 

Insufficient food may act to produce a scrofulous condition, by a mere 
failure to supply the demand caused by the breaking down of the old 
tissues. And unwholesome food may not only fail to supply the demand 
caused by the wastes of the system, but it probably furnishes materials 
of an impure character, which irritates the lacteals and perhaps other 
lymphatic vessels, as well as their glands. 

Gastro-enteritis, if long continued, produces scrofula, in part perhaps, 
by impairing digestion, and also by hindering the absorption of the chyle 
along the intestines. 

There are various other causes of scrofula, such as masturbation, 
sexual excesses, licentiousness, drunkenness, the use of tobacco, syphilis, 
or a syphilitic taint ; and the whole catalogue of improprieties and 
abuses of the system, to which the human family are addicted, in their 
present fallen and depraved condition. 

These causes, however, act in the same or a similar manner, by de- 
ranging nutrition and absorption ; and thus develop this fearful and 
complicated affection. 

Pathology. — From what we have already seen, the pathology or nature 
of this disease is very plain. And it is only necessary to remember that 
the functions of the mesenteric and other lymphatic glands are to modify, 
and especially to fibrinize the chyle and lymph; in order to discover the 
origin of the tuberculous matter, which exists in the blood, and is very 
liable to be deposited in this disease. 

For, as the mesenteric glands are diseased, the fat and albumen of the 
food is not changed to fibrin, as it should be ; and as the other lymphatic 
glands are involved, the albumen which transudes from the blood, every- 
where in the tissues, as well as the matter furnished by the breaking 
down of the old tissues, fails also to be modified and fibrinized, as it 
should be, by the lymphatic glands. 

Thus, then, we have in the blood, from imperfect digestion, and the 
mesenteric and other glandular derangements, an excess of albumen, 
and various morbid products, ready to be deposited in the glandular or 
other structures of the body, whenever a slight irritation, or other acci- 
dental cause, may chance to produce or create a predisposition to the 
deposit. 

Such, according to my view, is the pathology of one of the most inte- 
resting and complicated affections with which the human family are 
afflicted ; and which is yearly carrying to a premature grave many thou- 
sands, both male and female, and mostly at the dawn of, or during the 
early period of life. Well might we exclaim, in the language of one of 
old, in view of these facts, " Is there no balm in Gilead ? is there no 
Physician there ? why then is not the health of the daughter of my 
people recovered ?* 

This disease is really the result of the continued and multiplied im- 
prudence of the human family, from their first imprudent eating in the 
garden, to the present time. And the balm, for this mighty physical 

* Jeremiah viii. 22. 



SCROFULA. 565 

wound, consists in the correction of these imprudences, and a return to 
the strict observance of the laws of health and propriety, in every 
respect. Hence the following course of treatment is indicated in this 
disease. 

Treatment. — If the patient has any low or vicious habits, they should 
be inquired into and corrected. If addicted to the use of tobacco, to 
drunkenness, licentious habits, or any other species of imprudence, the 
fearful consequences should be pointed out, and the patient made to 
conform rigidly to the laws of health and propriety, in every respect. 
If the patient is exposed to filthy, damp air, in basements, as children 
often are, they should be removed at once to clean, dry. elevated apart- 
ments. 

If the patient has been illy clad so that the surface has not been kept 
warm, sufficient clothing should at once be furnished, with flannel to be 
worn next the skin, except in the very warmest weather, and in very 
bad cases, constantly. The patient should also be directed to sleep in 
flannel, and on no account to expose himself to become chilly for any 
length of time. By strict observance of these regulations, the morbid 
irritability of the lymphatics of the skin may in part be corrected or 
greatly relieved, and the general condition of the patient improved. 

If the patient has been in the habit of irregular eating, or of taking 
improper or unwholesome food, a good nourishing diet should be substi- 
tuted, to be taken at regular hours, and eating between meals should be 
strictly prohibited. This will not only improve digestion, but it will also 
furnish to the system a better supply of more healthy chyle, to satisfy 
the demand caused by the wastes of the system. 

If the patient has been addicted to sedentary or indolent habits, suffi- 
cient exercise in the open air should be enjoined, when the condition of 
the patient and the state of the weather will admit of it. This, by the 
aid it affords digestion, and in fact all the functions of the body, will 
often be of material service to the scrofulous patient. 

If the patient has been addicted to habits of filth, he should be directed 
to wash the body once or twice a week in tepid or cool water and soap, for 
the purpose of removing any dirt that may have accumulated on the skin. 

Such, I believe, are the principal indications in the treatment of scrofu- 
lous affections. In some cases, however, medical treatment is also indi- 
cated. 

If the bowels are constipated, as is frequently the case, a blue pill may 
be given at evening, for two or three days, and then a pill of aloes and 
rhubarb continued after dinner each day till they are regulated. 

If there is acidity of the stomach, two drachms of prepared chalk may 
be dissolved in half a pint of water, and of this a tablespoonful may be 
given every morning for a time. If the appetite is poor, moderate doses 
of the fluid extract of gentian or columbo, or else of the cold infusion of 
one of these tonics with a little ginger, may be given three times per day, 
and continued till the appetite is restored. 

In mild cases, in which there are no marked glandular indurations, 
the citrate cabonate, or ferrocyanuret of iron may be given in two or 
three grain doses three times per day, for a time, for the blood. In cases, 
however, in which there are glandular indurations, with or without ulcer- 
ation, five grains of the iodide of potassium with two grains of the solid, 



566 DISEASES OF THE CIRCULATORY SYSTEM. 

or ten drops of the fluid extract of conium should be given three times 
per day before eating. And if the prostration be considerable, ten drops 
of the syrup of the iodide of iron should be given three times per day, 
after eating, and continued till the blood is supplied with a due amount 
of iron. As an application to the indurated and enlarged glands, the 
compound iodine ointment will generally do best. 

In cases in which the digestion is very imperfect, but little chyle being 
furnished, and the absorbents are morbidly active, as is sometimes the 
case, producing emaciation, the cod-liver oil may be tried, and if it 
agrees with the stomach, it may be given for nourishment, in table- 
spoonful doses, three times per day, an hour after each meal. This may 
be continued, with such other treatment as is indicated, as long as its 
effects are salutary.* 

By thus correcting the habits of scrofulous patients, and doing just 
that which is indicated, and nothing more, many incipient cases may be 
arrested, bad cases palliated, and mild ones perhaps permanently cured, 
if there is not a strong hereditary predisposition to the disease. 

Much may be done by way of preventing the development of the dis- 
ease, in children born of scrofulous parents, by avoiding the causes that 
operate to call into activity the latent hereditary predisposition to the 
disease. The physician, then, should in such cases, and in fact in all 
cases, give such direction for the care and preservation of health, as 
shall not only prevent scrofula, but as far as possible all other diseases 
to which, by imprudence, mankind have become hereditarily predisposed. 

SECTION XXVIII.— BRONCHOCELE— ( Goitre.) 

By bronchocele, from jSpoy^os, "a bronchus," and **M, " tumor," I 
mean here an enlargement of the thyroid gland, of a non-malignant 
character, consisting merely in hypertrophy of the part. 

In order to understand this subject, it is necessary to remember that 
the thyroid gland is situated upon the trachea, its two lobes being placed 
one on each side ; the isthmus connecting them passing in front of its 
upper rings. Its structure consists " of an aggregation of minute inde- 
pendent membranous cavities, inclosed by a plexus of capillary vessels, 
and connected together by areolo-fibrous tissue." These minute cavities 
are filled with fluid, and the gland is larger in the young, and in females, 
than in adult males. 

The gland is supplied with blood by the thyroid arteries, and its 
nerves are derived from the superior laryngeal and sympathetic. 

The thyroid gland, thus situated and constituted, is liable to enlarge- 
ment from hypertrophy, the symptoms of which we will now proceed to 
consider. 

Symptoms. — This enlargement appears at first like a small tumor, on 
one or both sides of the trachea, which increases in size, more or less 
rapidly, till in some cases it finally occupies the whole anterior part of 
the neck. At first the tumor is soft, but as it progresses, some parts of 
it generally acquire considerable density, while other portions feel nearly 
natural. 

If the tumor becomes very large, it makes pressure on the trachea, 
oesophagus, and large blood-vessels, producing difficult breathing, diffi- 
* The hypophosphites may be indicated in some cases. 



BRONCHOCELE. 567 

culty of swallowing, and sometimes fatal congestion of the brain. I have 
known the tumor to produce palpitation of the heart, throbbing of the 
carotids, and, in one case, fatal apoplexy, in a lady not otherwise pre- 
disposed to cephalic congestion. 

Enlargement of the thyroid gland generally progresses slowly, so that 
it may occupy years in acquiring a large size. But some cases progress 
rapidly, the gland acquiring a large size in a few months. In a case 
that fell under my care, in an anaemic female, being associated with 
ameuorrhoea, and a prominence of the eye-balls, the tumor increased to 
a large size in six months, and it was subject to great variations in its 
size, the result evidently of accidental congestions. 

Diagnosis. — When a tumor appears occupying the place of the thy- 
roid gland, or one lobe of it, and moves with the larynx and trachea in 
the act of deglutition, and is moveable, insensible, soft and spongy to 
the feel, and free from pulsation, it is hypertrophy of the thyroid gland 
or bronchoceh. 

Causes. — All the causes which operate to develop a scrofulous condi- 
tion of the system, may produce bronchocele. But water impregnated 
with the carbonate or sulphate of lime, together with damp air, and a 
low electrical state of the atmosphere, such as generally prevails in 
valleys between high mountains, are probably the most frequent causes 
of this affection. 

The disease is very apt to come on in young females, in connection 
with suppression of the menses, attended also as we have seen in some 
cases, with prominence of the eye-balls, in decidedly anaemic patients. 

Prognosis. — The prognosis is favorable in all recent cases of broncho- 
cele, if the causes can be removed, and the patient be subjected to pro- 
per treatment in season. But in old protracted cases, if the patient is 
advanced in life, but little need be expected from remedial measures. 

Treatment. — The general condition of the patient should first be as- 
certained and corrected, and then if the goitre continues, iodine should 
be resorted to internally and externally, and continued till the broncho- 
cele is removed. 

For internal administration, Lugol's solution, made by dissolving a 
scruple of iodine, and two scruples of the iodide of potassium in seven 
fluid drachms of water, will generally do best. Of this solution, five drops 
may be given three times per day, at first, in a glass of sweetened water, 
and the dose may be gradually increased to fifteen or twenty drops. 

In case, however, the iodine in this form should disagree with the 
stomach, five grains of the iodide of potassium may be given three times 
per day, before eating, instead. And if there is an anaemic condition, 
ten drops of the syrup of the iodide of iron may be given three times 
per day, after meals, as an alterative and tonic. 

After having removed the causes, corrected the general condition, and 
had the patient on iodine internally for a time, an ointment should be 
applied to the tumors, two or three times per day, made by mixing two 
drachms of iodide of potassium, dissolved in a fluid drachm of boiling water, 
with an ounce of lard. Or, if the case should prove obstinate, two 
drachms of iodine may be added, in the preparation of the ointment to 
be used. This should be continued with the iodine internally, till the 
bronchocele is entirely removed. 



CHAPTER XL 

DISEASES OF THE EYE 



SECTION I.— CATARRHAL OPHTHALMIA. 

By catarrhal ophthalmia, I mean here that variety of inflammation of 
the conjunctiva which occurs from common colds, or from sudden expo- 
sure to cold, dampness, &c. 

But before we proceed to the consideration of this affection, let us 
take a general glance at the anatomy and physiology of the eye, that 
we may proceed understandingly. 

The general form of the eyeball is that of a sphere, about an inch in 
diameter, " having the segment of a smaller sphere engrafted upon its 
anterior surface, which increases its antero posterior diameter." 

The eye, that it may be a perfect organ of sight, is composed of three 
tunics, the sclerotic and cornea, the choroid iris and ciliary processes, 
and the retina and zonula ciliaris. It has also three humors, the aque- 
ous, crystalline and vitreous. 

The sclerotic and cornea form the external tunic of the eye, the 
sclerotic constituting four-fifths, and investing the posterior portion of 
the globe, while the cornea invests one-fifth of the eye anteriorly, being 
continuous with the sclerotic. 

The sclerotic is a dense fibrous membrane, continuous posteriorly with 
the sheath of the optic nerve, which is derived from the dura mater. 
Anteriorly, it has a beveled edge to receive the cornea. Its anterior 
surface is covered by the tunica abuginea, or expansion of the tendons 
of the four recti muscles. 

The cornea forms as we have seen, the anterior fifth of the external 
tunic of the eye, being transparent, concavo-convex, and set in the 
beveled edge of the sclerotic, in the same manner that a watch-glass is 
received by the groove in its case. The cornea is composed of several 
layers connected together by areolar tissue. 

The second tunic of the eye consists, as we have seen, of the choroid, 
ciliary ligament and iris. 

The choroid is situated immediately within the sclerotic, to which it is 
connected by a fine areolar tissue, and extends from the opening of the 
optic nerve forward to the edge of the iris, to which it is connected, and 
also to the ciliary processes, as well as the ciliary ligament. The choroid 
membrane is composed of three layers, an external venous, a middle, 
consisting mainly of minute arteries, and an internal layer, the mem- 
brana pigmenti. 

The ciliary ligament is a dense white structure which connects the 
cornea and sclerotic at their junction with the iris and external layer of 



CATARRHAL OPHTHALMIA. 569 

the choroid membrane. It contains the ciliary nerves and vessels, and 
has also a minute vascular canal called the ciliary canal, situated within it. 

The iris makes up the anterior portion of the second tunic of the eye. 
It is situated in the middle of the aqueous humor, and separates the an- 
terior and posterior chambers, being pierced near its centre by the 
pupil. It is made up of blood-vessels, muscles, and nerves, which are 
connected by fine cellular tissue. There is probably a circular muscular 
tissue passing around the pupil, which serves by its action to contract it. 
And there appears to be radiating muscular fibres passing to the circum- 
ference of the iris, which by contracting dilate the pupil. 

The ciliary processes which are an appendage developed from the inner 
surface of the middle tunic of the eye, consist of triangular folds, formed 
by the plaiting of the middle and internal layer of the choroid coat. 
" Their periphery is connected with the ciliary ligament," and continu- 
ous with the middle and internal layer of the choroid, while its central 
border is free, resting against the circumference of the lens. " The an- 
terior surface corresponds with the uvea, the posterior receives the folds 
of the zonula ciliaris between its processes," thus establishing a connec- 
tion between the choroid and third tunic of the eye. The ciliary pro- 
cesses are covered with an abundant layer of pigmentum nigrum. 

The third tunic of the eye as we have seen, is the retina, with its an- 
terior prolongation, the zonula ciliaris. 

The retina is composed of three layers, and external very thin, called 
Jacob's membrane, a middle or nervous, consisting of an expansion of 
the optic nerve, and an internal vascular membrane, consisting of the 
ramifications of the central artery of the retina, and its accompanying 
veins. 

The zonula ciliaris is a thin vascular membrane which connects the 
anterior border or margin of the retina, with the anterior surface of the 
lens near its circumference. Its under surface is in contact with the 
hyaloid membrane, and it forms around the lens the anterior wall of 
the canal of Petit. 

The aqueous humor is a transparent albuminous fluid which occupies 
the anterior and posterior chambers of the eye, or the small spaces an- 
terior and posterior to the iris. These chambers are lined by a mem- 
brane which secretes this fluid. 

The vitreous humor forms the posterior three-fourths of the bulk of 
the eye, and consists of an albuminous, gelatinous, and highly transparent 
matter enclosed in the hyaloid membrane. From the hyaloid membrane 
lamellae pass inwards, forming compartments, which contain the fluid. 
And along the centre of the vitreous humor, there is a canal which con- 
ducts an artery from the central artery of the retina to the capsule of 
the crystalline lens. 

The crystalline lens is imbedded in the anterior portion of the vitreous 
humor, from which it is separated by the hyaloid membrane, and just 
back of the pupil, and posterior chamber of the eye. It is surrounded 
by the ciliary processes, invested by a transparent membrane or capsule, 
"retained in its place by the attachment of the zonula ciliaris," and im- 
mediately around its circumference is the triangular canal of Petit. 

The crystalline lens is transparent, and composed of concentric layers, 



570 DISEASES OF THE EYE. 

the external being soft, and easily removed, while the internal grow 
more firm, till a central hardened nucleus is reached. 

Thus we have at a glance the different tunics and humors of the eye. 
And it should be remembered, that the sclerotic is for protection ; the 
cornea for the transmission of light to the eye, and the choroid for nu- 
trition ; its pigmentum nigrum also absorbing scattered rays of light. 
The iris regulates the amount of light to be admitted: and the humors, 
together with the cornea, refract the rays of light, so that the image of 
objects may fall on the retina, by which the impressions are communi- 
cated to the gray matter of the hemispheres of the brain, and thence to 
the mind itself. 

The appendages of the eye, consisting of the eye-brows, eye-lids, eye- 
lashes, caruncula lachrymalis, and lachrymal apparatus, we need not 
stop to examine, as their diseases are mostly surgical. But it should be 
remembered, that the eye is kept back in its socket, and turned in dif- 
ferent directions, by the four recti and superior and inferior oblique 
muscles, and also that the conjunctiva, a mucous membrane, covers the 
whole anterior surface of the eye, and then is reflected upon both lids, 
forming their internal or lining membrane. It is, in fact, catarrhal in- 
flammation of this membrane which constitutes the legitimate subject of 
this section ; the symptoms of which we will now proceed to consider. 

Symptoms. — The early symptoms of catarrhal ophthalmia are, in addi- 
tion to the general symptoms of an ordinary cold, more or less uneasi- 
ness on exposure to light, with slight redness and pain in the temples. 
As the disease advances, the pain and intolerance of light become more 
marked, and in severe cases there is more or less catarrhal fever, head- 
ache, loss of appetite, nausea, &c. 

When the conjunctival inflammation is fully established, there is an 
increased mucous discharge, with very considerable redness of the mem- 
brane. The redness, however, is generally superficial, and of a bright 
scarlet color ; the distended vessel appearing quite superficial. 

Catarrhal conjunctivitis is seldom attended with much swelling ; the 
only approach to such a condition being an elevation, caused by a slight 
effusion of serum, under the membrane. And unless in very severe 
cases, in which there may be thickening, the sclerotic coat may be seen 
through the inflamed conjunctiva, of its natural white color. The symp- 
toms of catarrhal ophthalmia, like those of other catarrhal affections, 
generally remit by day, and undergo exacerbations at night, during the 
whole progress of the disease. 

Diagnosis. — Catarrhal ophthalmia may be distinguished by the attend- 
ant catarrhal symptoms, by the diurnal remissions, and nocturnal ex- 
acerbations, by the mucous discharge and by the natural appearance of 
the sclerotica, as well as the bright red tint of the conjunctiva. 

This affection may be distinguished from purulent ophthalmia, by its 
mildness when compared with that disease, by the mucous instead of 
purulent character of the discharge, and by its non-contagious character. 

Causes. — It is probable that common colds, from various exposures, 
are the most frequent causes of catarrhal ophthalmia. The disease may, 
however, be produced by causes, such as cold and moisture, acting 
directly upon the eye. Or it may be caused by exposure to winds, 



PURULENT OPHTHALMIA. 571 

storms, &c, probably in cases in which the system generally does not 
suffer very materially. 

Prognosis. — As this form of ophthalmia is generally confined to the 
conjunctiva, it usually terminates favorably, unless the case be neglected, 
or what is much worse, is subjected to harsh or improper treatment. 
With either of these misfortunes, the sclerotica and cornea, may become 
involved in the inflammation, and thus opacity of the cornea, or other 
serious consequences follow. 

Treatment. — In the treatment of catarrhal ophthalmia, mild measures 
only, are usually required. 

The patient may take two or three blue pills at evening, and follow 
them in the morning, by half an ounce of the sulphate of magnesia ; 
and then the bowels may be kept loose by a teaspoonful, taken each 
morning, for a few days. 

A warm pediluvium, should be used, at evening, each day, and if the 
inflammation is severe, cups may be applied to the temples, or back of 
the neck, at first ; and later, if necessary, blisters back of the ears, or 
to the back of the neck. 

Warm milk and water, is the best application for the eyes, for the first 
day or two. Later, a wash made by dissolving three grains of the 
acetate of zinc, and one and a half grains of the acetate of morphia, in 
an ounce of rain water, will generally do best. Or the wash may be 
made, by infusing five grains of opium, in an ounce of rain water, with 
three grains each of the acetate of lead, and sulphate of zinc; and then 
strain or filter. The wash should be applied four times per day, till a 
cure is effected. 

SECTION II.— PURULENT OPHTHALMIA. 

By purulent ophthalmia, I mean here, that variety of acute inflamma- 
tion of the conjunctiva, attended with a copious secretion of matter, 
resembling pus; the inflammation tending strongly, unless arrested, to 
pass to the cornea, producing sloughing, suppuration, ulceration, opacity, 
&c. 

Symptoms. — Purulent ophthalmia may occur in the infant, or in the 
adult, and in either case, consists at first, of an inflammation of the con- 
junctiva of the lids, extending with more or less rapidity, to that portion 
of the membrane covering the eyes, and in bad cases, involving the cor- 
nea; attended in all cases, with a copious purulent discharge. 

The disease may occur in early infancy, two or three days after birth, 
or at a later period, during childhood. At first, the lids are noticed to 
stick together, when the child wakes from sleep; the edges of the lids 
are redder than natural, and the child appears to suffer from the access 
of light. If the lids be inverted, their lining is found red, and more or 
less white mucus or purulent matter is found inside the lower lid. 

Soon, however, the inflammation extends to that part of the conjunc- 
tiva covering the eyes, the vascular congestion, and redness, being 
considerably augmented. The lids swell, and become red externally; a 
copious secretion of purulent fluid issues from the eyes; the intolerance 
of light becomes more marked, and the swelling of the conjunctiva 



572 DISEASES OF THE EYE. 

sometimes goes on, to an incredible extent. I have seen that portion of 
the conjunctiva covering the globe, so distended, that there was only a 
small passage down to the cornea, which had become deeply buried in 
the tumefied and projecting membrane. 

If the disease passes on unchecked, the inflammation may extend to 
the sclerotic and other tissues of the eye, and especially to the cornea, 
producing sloughing, suppuration, ulceration, and opacity, with perhaps 
adhesion of the iris to the cornea. 

The symptoms and progress of purulent ophthalmia in the adult, are 
similar to those which occur from the disease in infants, modified in their 
course and duration by age, and other circumstances of exposure, &c. 
The inflammation commences in the conjunctiva of the lids, and passes 
to that portion which covers the eye, and, unless arrested, may extend 
to the other tunics or tissues of the eye, and especially to the cornea. I 
believe the progress of the disease is generally less rapid than in infants, 
but neglected cases may pass on to sloughing, suppuration, ulceration, 
opacity of the cornea, &c. Perhaps the swelling of the conjunctiva is 
generally less in the adult ; but I have seen that portion covering the 
globe so much swelled or distended as to nearly hide the cornea, only a 
small passage being left down to it. 

Such, I believe, are the ordinary symptoms of purulent ophthalmia, as 
it occurs in the infant and adult, liable, of course, to modifications, from 
peculiarity of constitution, and various accidental causes. 

Diagnosis. — Purulent ophthalmia may be distinguished from catarrhal 
by the severity of the attack ; the purulent appearance of the discharge ; 
by the swelling of the lids and conjunctiva; and finally, by its tendency 
to pass on to destructive disorganization of the cornea, and other tissues 
or tunics of the eye. 

Causes. — It appears probable that purulent ophthalmia, as it occurs 
in infants, may be caused by the contact of gonorrhceal or leucorrhceal 
matter, derived from the mother at birth. But I believe that the dis- 
ease may be caused by want of cleanliness, exposure to cold, improper 
nourishment, want of care, &c, without the contact of gonorrhoea! or 
leucorrhceal matter from the mother. 

I am satisfied too, from careful observation, that the disease is con- 
tagious ; being communicated from one person to another, by accidental 
contact of the matter discharged. And it is probable that this may be 
the most frequent origin of the disease in adults. I believe, however, 
that it is sometimes produced in the adult by the direct contact of 
gonorrhoeal matter ; and perhaps it may sometimes be generated, as in 
the infant, by filth, exposure to cold, improper food, &c. 

Prognosis. — The prognosis in purulent ophthalmia is favorable, whe- 
ther it occurs in infants or adults, provided the cause or causes can be 
removed, and the case be subjected to proper treatment in season. 

If, however, the causes continue to operate, and the case be neglected, 
or improperly treated in its early stages, the worst results may be ap- 
prehended, and will generally be realized. Recoveries occasionally take 
place, however, after almost every unpleasant symptom, except utter 
disorganization have been developed. 

Treatment. — In the treatment of purulent ophthalmia of infants, a 



PURULENT OPHTHALMIA. 578 

grain of calomel may be administered, in a teaspoonful of castor oil, at 
first, and a little oil occasionally administered during the continuance of 
the disease. 

If the attack is severe, a leech or two may be applied to the lids, or a 
blister applied to the temples, or to that of the affected side, if one eye 
only is involved. 

The eye should be washed, morning and evening, with a little warm 
milk and water, and a solution of six grains of alum, in an ounce of rain 
water, should be applied to the eye, every four or six hours. Or a cloth 
wet with the solution may be kept constantly over the eye while the 
child is lying quietly, so that it need not be bound on. The alum wash 
produces no uneasiness, and being a good stringent, is the very best 
application in the purulent ophthalmia of infants. 

With this course of treatment, I have never failed of arresting the 
disease in infants and young children, in a few days, if resorted to in 
season. 

In the purulent ophthalmia of adults, as well as of infants, if any 
causes or influences are operating to keep up the disease, they should be 
removed, as far as possible. 

A cathartic of calomel should be administered at first, in castor oil, 
and a blue pill given for the two or three succeeding evenings, followed 
in the morning by a teaspoonful or more of the sulphate of magnesia. 

During the first five or six days, one-sixth of a grain of tartar emetic 
may be given every four hours. The eyes should be washed morning 
and evening with warm milk and water, and a saturated solution of alum 
in rain water should be applied every hour or two during the clay, and 
through the night small linen cloths, wet in the solution may be laid 
loosely over the eyes. 

Cups may be applied at first to the temples, and if necessary, leeches 
to the eyelids, and later, blisters may be required to the temples, back 
of the ears, or to the back of the neck. 

After the first five or six days, and as the inflammation begins to sub- 
side, if there is a cloudiness of the cornea, five grain doses of the iodide 
of potassium should be given every six hours at first. The tartar emetic 
should be suspended, and four grains of James's powder given instead, 
every six hours, alternating with the iodide of potassium. 

This treatment should be continued, with the alum wash to the eyes, 
till the inflammation is subdued, when the antimonial should be sus- 
pended, and the iodide of potassium continued in five grain doses, three 
times per day, till perfect transparency of the cornea is restored. 

If, as the inflammation subsides, the lids are found granulated, they 
should be touched, once each day, with a camel-hair pencil, wet with a 
saturated solution of nitrate of silver, the upper lid being turned up, an 
assistant immediately injecting on to the part touched, from a small 
glass syringe, a jet of cool rain water, to prevent the impression beino- 
too strong, and to wash the caustic over other parts of the eye. By 
this treatment the granulations will be removed in a few days, at the 
same time that the conjunctiva of the globe and lower lid will also be im- 
proved by the caustic that falls on them in a diluted state. 

If, after the inflammation and granulations, if they have existed, are 



574 DISEASES OF THE EYE. 

removed, there should remain slight redness and irritability of the con- 
junctiva, a wash may be applied for a time, made by dissolving two grains 
of the acetate of zinc, and a grain of the acetate of morphia, in an 
ounce of rain water. It may be applied four times per day, and con- 
tinued till the conjunctiva assumes a natural appearance. 

SECTION III.— SCROFULOUS OPHTHALMIA. 

By scrofulous ophthalmia, I mean that peculiar inflammation of the 
conjunctiva, extending sometimes to the sclerotica and cornea, which oc- 
curs in scrofulous patients, and depends mainly upon a scrofulous condi- 
tion of the system, either hereditary or acquired. 

Symptoms. — In addition to the ordinary symptoms of scrofula, the 
patient exhibits an intolerance of light, and very soon a slight redness 
of the conjunctiva occurs, at first perhaps confined mainly to the lining 
of the lids. By degrees, however, the conjunctiva covering the eye be- 
comes involved, particular vessels, or a collection of them enlarge, or be- 
come distended, and run to the edge of the cornea, stopping abruptly at 
the junction of the sclerotic and cornea, or else in severe or protracted 
cases extending over it. 

"Where these vessels terminate, whether over the sclerotica, at the junc- 
tion of the sclerotic and cornea, or on the surface of the cornea, small 
elevations or pustules may often be found, of a whitish or yellowish ap- 
pearance. These pustules in protracted cases, are liable to enlarge at 
times from slight causes, and they may become the seat and occasion of 
ulceration. 

The occurrence of these elevations are peculiar to scrofulous ophthal- 
mia, and though they are generally present in this affection, they are not 
invariably so. I have just examined a protracted case, in which, with 
occasional exacerbations, these pustules become the seat of ulceration of 
the cornea. 

In all cases of this disease, whether mild or severe, intolerance of light 
is the characteristic symptom. As a consequence of this intolerance, 
the patient generally goes with the head down, or if looking up, passes 
the hand over the eyes, as a temporary shade. Another peculiar symp- 
tom of scrofulous ophthalmia which I have noticed, is the occasional ten- 
dency to spasmodic closure of the lids, without the possibility of opening 
them, in consequence of a powerful contraction of the orbicularis pal- 
pebrarum. 

In one case of this character that fell under my care a few years since, 
the contraction of the orbicularis was so powerful that the natural open- 
ing between the lids had the appearance of a slightly oval passage spas- 
modically closed. This spasmodic closure of the lids had continued for 
several days, when I first saw the patient, and was only overcome by re- 
peated cupping of the temples, and back of the neck, together with the 
free application of an infusion of stramonium. 

This spasm when it occurs, as well as the excessive intolerance of 
light in this disease, is evidently the result of an irritable or sensitive 
state of the retina, and this I believe in turn, is often sympathetic, the 
result of irritation of the alimentary mucous membrane. 



SCROFULOUS OPHTHALMIA. 575 

Scrofulous ophthalmia is very often associated with that form of scro- 
fulous diseases, in which there are watery or mattery pimples on the 
face, and a scaly eruption hack of the ears, and perhaps covering most 
of the scalp. 

Scrofulous ophthalmia may continue more or less troublesome for a 
considerable time, and yet no very material changes take place in the 
structure of the eye. More generally, however, even in cases in which 
there is no very marked redness, an insidious change of structure takes 
place, especially in the cornea. 

The most frequent organic changes are permanent opacity, or ulcera- 
tion of the cornea at the seat of the pustules referred to, enlargement of 
the blood-vessel of the corneal portion of the conjunctiva, with thicken- 
ing and opacity of this portion of the membrane, dullness of the cornea 
from interstitial deposition, with enlargement of the proper vessels of the 
cornea, adhesion of the iris to the cornea, and finally more or less change 
of the sclerotic coat, iris, and other deeper parts, and in the general 
form of the eye. 

Diagnosis. — Scrofulous ophthalmia may be distinguished by the intole- 
rance of light, by a copious lachrymal secretion, by the pustular eleva- 
tions of the conjunctiva, with enlargement of its blood-vessels, and finally 
by the pimply or scaly eruptions back of the ears, or on the scalp and 
face, together with the symptoms of a general scrofulous condition of 
the patient. 

Causes. — Strumous ophthalmia may be produced by any cause or train 
of causes, capable of generating a scrofulous condition, or of developing 
it in constitutions hereditarily predisposed. I believe, however, that this 
form of scrofulous disease is most frequently produced by exposure to 
filth, dampness and cold winds, insufficient or unwholesome food, irregu- 
lar eating, masturbation and sexual excesses, the use of tobacco, drunk- 
enness and licentiousness, and other like improprieties, practiced either 
by the patient himself, or by his progenitors. 

Prognosis. — The prognosis is rather unfavorable in this disease, so far 
as the general restoration of the system is concerned. 

The ophthalmia may, however, generally be removed or relieved, tem- 
porarily at least, by a judicious course of general and local treatment, 
provided the cornea is only opaque, with enlargement of its vessels, with- 
out ulceration or other serious structural change. In fact, I have known 
cases to recover, after all distinction between the appearance of the 
sclerotic and corneal portions of the external tunic of the eye had 
entirely disappeared, an instance of which fell under my care, within 
the past two years. 

If, however, there are deep ulcerations of the cornea, attended with 
general opacity, and also a change in the structure of the iris and 
sclerotica, the prognosis is decidedly unfavorable. 

Treatment. — The treatment for scrofulous ophthalmia must be general 
and local, and the causes that are operating to produce or keep up this 
condition must also be removed. 

The patient should be kept clean, warm and dry, and should take a 
reasonable amount of good wholesome food with regularity. Sufficient 
exercise should also be allowed, and the patient should preserve an even 
and cheerful temper of mind. 



576 DISEASES OP THE EYE. 

If the patient has any low, vicious habits, they should be corrected, 
and a rigid observance of the laws of health should be insisted upon, in 
every respect. This being arranged, the general condition of the patient 
should be corrected as far as possible, by such measures as are indicated. 
If the bowels are constipated, and the patient is a child, a dose of mer- 
cury with chalk, and rhubarb may be administered in castor-oil, at first, 
and the bowels kept regular if necessary by equal parts of rhubarb and 
the sulphate of magnesia. 

If the patient is an adult, three blue pills may be given at first, at 
evening, and a full dose of the sulphate of magnesia administered on the 
following morning, after which a pill of aloes and rhubarb may be given 
each day after dinner, and continued till the bowels are regulated. If 
the patient is feeble, a grain or two of the sulphate of quinine may be 
given, mingled in water, with twice the quantity of prepared chalk, and 
this should be continued till the appetite and digestion are in a measure 
restored. If there is great intolerance of light, cups, wet or dry, may 
be applied to the temples at first, and later blisters should be applied 
back of the ears and to the back of the neck, and these should be re- 
peated if salutary, during the continuance of the disease. If the light 
cannot be borne, the eyes may be protected and soothed by pieces of 
double linen, hanging loosely over them, supportod by a belt passing 
around the head, the eye pieces being kept wet in an infusion of stramo- 
nium made from two drachms of the leaves to a pint of water. 

In some cases, no other application may be required for the eyes. If, 
however, there is considerable redness of the conjunctiva, the eyes may 
be washed four times per day with a saturated solution of alum in rain 
water, containing also a fluid drachm of the wine of opium to the ounce. 

After having continued the quinine for a reasonable time when it is 
indicated, and immediately after the operation of the first cathartic in 
cases in which it is not, five grain doses of the iodide of potassium, 
should be given three times per day, in the fluid extract or compound 
decoction of sarsaparilla, and in cases in which there is opacity of the 
cornea, it should be continued till the opacity is entirely removed. 

When this is accomplished, the iodide of potassium should be suspended, 
and the sarsaparilla continued with ten drop doses of the syrup of the 
iodide of iron, three times per day, till the blood and general condition 
of the system is restored as far as it may be. The patient should then 
with all possible prudence avoid the causes calculated to produce a 
return of the disease. 

SECTION IV.— KHEUMATIC OPHTHALMIA. 

By rheumatic ophthalmia, I mean here rheumatic inflammation of the 
tunics of the eye, having its special seat in the fibrous structure of the 
sclerotica, but extending in most cases more or less to the conjunctiva 
cornea and iris, and sometimes to other tunics or structures of the eye. 

As the sclerotica is a fibrous structure, it is as we should suppose, the 
most frequent seat of rheumatic inflammation of the eye. And as the 
cornea, iris and conjunctiva are parts with which it is either directly or 
indirectly connected, it is not strange that these parts should become 
more or less involved in rheumatic ophthalmia. 



RHEUMATIC OPHTHALMIA. 577 

Symptoms. — Rheumatic ophthalmia generally occurs in persons of a 
rheumatic diathesis, and very generally in those of shattered or broken 
down constitutions, who have suffered more or less from the disease in 
other parts. It is very apt, according to my observation, to be associ- 
ated with catarrh of the Schneiderian membrane, and may be attended 
with general febrile excitement, or it may occur without fever, being 
attended with the general symptoms of depression. 

In addition to the general febrile symptoms, w T hen they attend, there 
js early, pain in the temples, and more or less heavy dull pain in the 
eyes, with either dryness or increased lachrymation, slight intolerance of 
light, and more or less redness. 

The redness generally begins around the cornea, from which point en- 
larged vessels may be seen passing in every direction, in straight lines. 
If, however, the conjunctiva becomes involved, the enlargement of its 
vessels, which instead of being straight, are irregular and tortuous, may 
obscure those of the sclerotica beneath. 

The cornea, if it is involved, may assume a dull appearance, but it 
seldom if ever becomes opaque in rheumatic ophthalmia, in the early 
stages at least. If, however, the iris is involved, the pupil is apt to be 
contracted and irregular, and the change in its structure may cause ir- 
regular projections, and perhaps extinction of sight. The redness of the 
sclerotic coat is of a pink color, and in protracted cases it may extend 
and give its whole surface this peculiar appearance. 

As the disease advances, the patient complains of a stiffness, fullness, 
and dull aching or throbbing sensation in the eye, which extends to the 
back of the orbit, and sometimes to the corresponding side of the head. 

Rheumatic ophthalmia is always aggravated by storms or damp weather, 
and there is generally an increase of the pain during the night. Such, 
according to my observation, are the ordinary symptoms of rheumatic 
ophthalmia. The disease is liable, however, to great variations, from a 
slight pain, redness and dryness or stiffness of the eyes, to those aggra- 
vated and protracted cases, in which all the tunics of the eye become 
involved, leading on, in some cases, to a permanent loss of sight. 

Diagnosis. — Rheumatic ophthalmia may be distinguished by the 
rheumatic condition of the patient ; by the dull aching character of the 
pain ; by the enlargement of the sclerotic vessels, and peculiar pink 
color of the membrane ; and by the aggravation of the pain at night, 
and of all the symptoms during storms or damp weather. 

Causes. — It is probable that in addition to a general rheumatic con- 
dition of the system, various exciting causes operate to develop this 
disease, such as exposure to winds, storms and dust ; a stooping posture, 
protracted grief, catarrh of the Schneiderian membrane ; and various in- 
fluences which tend to irritate the organ. 

Prognosis. — In recent cases of this disease, occurring in constitutions 
not too much enfeebled, the prognosis is favorable if the iris is not 
materially involved. But in very protracted cases of rheumatic ophthal- 
mia, occurring in broken down constitutions, the prognosis is unfavorable, 
especially if, as is often the case, all the tunics of the eye have been 
involved, and have undergone more or less change. In case, however, 
the iris has undergone no material structual change, some desperate 
37 



578 DISEASES OF THE EYE. 

and protracted cases of this disease finally recover ; several instances of 
■which I can now call to mind, in cases that have fallen under my care. 

Treatment. — If the patient is plethoric, and the attack is acute, and 
attended with general febrile excitement, blood may be taken from the 
arm, but not otherwise. Cups, however, wet or dry, should be applied 
to the temples or back of the neck in all cases; and later, blisters either 
to the temples, back of the ears, or to the back of the neck if necessary, 
and repeated while the inflammation continues. 

A cathartic of calomel and castor-oil should be administered at first, 
and a regular action of the bowels secured by small doses of the sulphate of 
magnesia, during the continuance of the disease. 

Immediately after the operation of the cathartic, in active cases at- 
tended with fever, fifteen grains of nitre may be given every six hours, 
in a tumbler of warm crust coffee, and continued till the fever subsides. 
As the fever subsides, in cases in which the nitre has been indicated and 
administered, or immediately after the cathartic in cases in which no 
general fever attends, the iodide of potassium should be given in ten 
grain doses three times per day, with twenty drops of the wine of col- 
chicum, or ten drops of the fluid extract. This should be continued 
till the disease is materially checked, with warm pediluvia at evening, 
and occasional doses of the sulphate of magnesia if necessary for the 
bowels. 

After the ophthalmia is in a good degree controlled, the colchicum 
may be omitted, and the iodide of potassium continued, in five grain 
doses, three times per day, in the fluid extract, or compound decoction 
of sarsaparilla. And this should be continued till a final cure is effected, 
which may require several weeks, or even longer than that. 

The patient should be kept clean and dry, and allowed a plain diges- 
tible diet, to be taken with strict regularity, during the continuance of 
the disease. 

SECTION V.— CORNEITIS. 

By corneitis, I mean here, inflammation of the cornea, whether 
traumatic, or spontaneous, and associated with depravity of the blood or 
a scrofulous condition of the system. 

The cornea, it will be remembered, is the anterior transparent pro- 
jecting portion of the outer tunic of the eyes. Its vessels, though quite 
numerous, are not visible in a natural, or perfectly transparent state of 
the part; but they become so, if the cornea is inflamed, the vessels then 
being enlarged, and admitting red blood. 

We have seen that the cornea is liable to become inflamed, by exten- 
sion from other tissues of the eye. We are now to examine the disease, 
as it is developed primarily in the cornea; whether it arise from direct 
injury of the cornea, or spontaneously, in an acute or chronic form. 

It should be remembered, that the vessels of the cornea, are suffici- 
ently numerous, to produce a general redness ; if they become generally 
enlarged, as they do under active or long continued congestion or in- 
flammation. 

Corneitis is attended with a peculiar train of symptoms, which we will 
now nroceed to consider. 



CORNEITIS. 579 

Symptoms. — When corneitis occurs from direct injury; several cases 
of which have fallen under my care, during the past few years ; in ad- 
dition to an opacity at the point of injury, the cornea assumes a general 
cloudy appearance. Its blood-vessels are more or less enlarged, as well 
as those of the sclerotica, and besides a cloudiness of the cornea, and 
more or less redness of the sclerotica and conjunctiva, a pink zone is 
seen encircling the cornea, in most cases that I have observed. I now 
distinctly remember three cases, in which the cornea was perforated, 
with more or less escape of the aqueous humor; attended in one case 
with protrusion of the iris. In these cases, in addition to the above 
symptoms, there was slight flattening of the eye, and very considerable 
intolerance of light. 

In all these cases the inflammation was subdued, and the opacity of 
the cornea removed, except at the point of injury ; but unfortunately in 
one of the cases, from subsequent neglect on the part of the patient, 
there was the supervention of cataract. 

Spontaneous Corneitis, or that which occurs independent of local in- 
jury, from depravity of the blood, or a scrofulous condition of the system, 
may be either acute or chronic. When it is acute, the symptoms are 
similar to those already laid down as belonging to traumatic cases, with 
the exception of the marks caused by the intruding substance. 

But spontaneous corneitis is generally of a decidedly chronic character, 
being passive, and associated with a depraved and feeble condition of the 
system, in which case there is at first, slight dullness of the cornea, with 
imperfect vision, and by degrees an enlargement of its vessels, as well as 
those of the sclerotica and conjunctiva. 

By degrees the surface of the cornea assumes a granulated appear- 
ance ; the enlargement of its vessels become more apparent ; its circum- 
ference assumes a dark reddish color ; and, in addition to a pink zone 
round the cornea, the whole sclerotica is covered by a plexus of distended 
vessels. 

This form of corneitis is attended with pain, and a sense of tightness 
in the eye ; and there is generally, especially in scrofulous patients, in- 
creased lachrymation, and considerable intolerance of light. 

Corneitis, if neglected, is liable to lead on to a general and permanent 
opacity of the cornea, and to various structural changes. And as the 
iris, sclerotica, and other membranes of the eye, generally become more 
or less involved, there is liable to be, in protracted cases, serious organic 
changes in their structure. 

Such, according to my observation, are the ordinary symptoms of cor- 
neitis, liable, of course, to variations, from the nature of the cause, as 
well as from the general condition of the patient, &c. 

Diagnosis. — Traumatic cases of corneitis may readily be distinguished, 
as it is indicated by the nature of the cause. In distinguishing sponta- 
neous cases however, it is necessary to bear in mind all the symptoms 
peculiar to this form of ophthalmia; and especially the early cloudiness 
of the cornea, and roughnesss of its surface ; as well as the gradual 
extension of the inflammation to the iris, sclerotica, and conjunctiva, in 
cases in which they have become involved. 

Causes. — Corneitis, as we have seen, may be produced by a wound of 



580 DISEASES OF THE EYE. 

the part, either bruising, penetrating, or perforating its structure. 
Spontaneous cases, however, may be the result of every variety of im- 
prudence which depraves the blood, or produces or develops a scrofulous 
condition of the system. The direct exciting causes, are exposures of 
various kinds, such as to winds, storms, dust, smoke, heat, &c. 

Prognosis. — The prognosis in recent cases of corneitis is favorable, if 
the causes can be removed, and the patient be subjected to proper treat- 
ment. 

If, however, the case be neglected, and the inflammation extends to 
other parts of the eye, involving the iris, serious structural changes of 
the cornea, iris, or other important parts, are very liable to take place. 
In this case, vision may be impaired, or even permanently destroyed. I 
believe, however, from my own observation, in the treatment of corneitis, 
that it is as susceptible of relief from proper remedial measures as any 
form of ophthalmia. 

Treatment. — The cause should first be sought out and removed, and 
the habits of the patient corrected ; after which the case should be treated 
according to the general and local condition of the patient. 

If the case is acute, whether the result of direct injury, or spontaneous, 
blood should be taken by cups, from the temples or back of the neck, 
and if necessary leeches should be applied about the eyes. A cathartic 
of calomel should be administered in castor-oil, and tartar emetic in one- 
sixth of a grain doses administered every four hours, alternating with 
alterative doses of calomel, or mercury with chalk. 

After having subdued the febrile symptoms in such cases, and imme- 
diately after the first cathartic, in chronic or passive cases, the patient 
should take a blue pill at evening, and a teaspoonful of the sulphate of 
magnesia each morning ; the antimony and alterative doses of mercurial 
having been suspended, or omitted, if the case is chronic. 

Blisters should be applied to the temples, back of the ears, and to the 
back of the neck, and these should be repeated in succession while the 
inflammation continues, so that as one heals, another shall be drawn and 
ready to discharge. 

After having continued the blue pill at evening as long as the severity 
of the inflammation may seem to require, it may be suspended, and 
moderate doses of leptandrin, or of the sulphate of magnesia, adminis- 
tered occasionally, if the state of the bowels renders a laxative necessary. 
On suspending the blue pill, the iodide of potassium should be given in 
five grain doses, three times per day, before eating ; and if the patient 
is anaemic, ten drops of the syrup of the iodide of iron should be given, 
after meals, and continued till the ophthalmia and its effects are re- 
moved. 

SECTION VI.— IKITIS. 

By iritis, is here meant inflammation of the iris, and especially that 
variety of the disease in which the iris is the primary seat of the inflam- 
mation, though the disease may be the result of extension of inflamma- 
tion from other parts of the eye, as we have seen. 

The iris, it will be remembered, forms the septem between the anterior 



IRITIS. 581 

and posterior chambers of the eye, being pierced near its centre by a 
circular opening, the pupil. 

It is connected by its periphery with the ciliary ligament, and its inner 
circumference forms the margin of the pupil. Its anterior surface is 
muscular ; the circular portion surrounding the pupil being for its con- 
traction, while the radiating fibres, in a healthy state, have the power of 
dilating the pupil. Its posterior layer is of a deep purple color, and has 
been called the uvea, from its resemblance in color to a ripe grape. 

The arteries of the iris are furnished by the long ciliary arteries, and 
form two circles, by their anastomoses, the one broad, near its great cir- 
cumference, the other smaller, surrounding the circumference of the 
pupil. Its veins empty mostly into the long ciliary veins. The iris is 
also well supplied with nerves, and by its contraction or dilatation, it 
regulates the quantity of light proper for distinct vision. 

The iris thus situated and constituted, is liable to become inflamed, 
and, when it does, a peculiar train of symptoms are developed, which 
we will now proceed to consider. 

Symptoms. — In some acute cases of iritis, there is the development of 
severe febrile symptoms, attended with restlessness, headache, want of 
sleep, a strong full pulse, a white tongue, thirst, &c. More generally, 
however, these symptoms are very slight, or entirely absent. 

The most general local symptoms of iritis are change of color of the 
iris, effusion of lymph, imperfect motion of the iris, and an irregular 
pupil, increased redness of the eye, a change of the cornea, pain and 
intolerance of light, and finally a gradual progress, either towards reco- 
very, or else in the destructive process, such as a change of color or 
texture, adhesion of the pupil, a membraneous closure of the pupil, or 
by contraction, atrophy of the globe, with fluidity of the vitreous humor, 
and, finally, blindness, or impaired vision. 

The change of color in iritis commences early, in the edge of the pupil, 
and gradually extends to the ciliary edge of the iris. It is caused by 
effusion into its texture, and presents, with a loss of brilliancy of the 
iris, a dark reddish, green or yellowish tinge, which may readily be dis- 
covered, if it be compared with the iris of the sound eye. 

The effusion of lymph may be only into the texture of the iris, or, if 
the iritis passes unchecked, a layer of lymph may be deposited on its 
surface, or into the anterior or posterior chamber, in a partially detached, 
loose mass, as happened in one case that fell under my care ; or, finally, 
the lymph may appear in small elevations on the surface of the iris, or 
edge of the pupil, or it may form bands across the pupil, or completely 
close it. 

The motions of the iris are impaired from the first, and as the effusion 
of lymph takes place, it is often entirely suspended, the pupil being con- 
tracted, and very irregular. 

Increased redness of the eye generally attends, being noticed first 
around the cornea, in the form of a pink zone. It gradually extends, 
however, to the sclerotica, and especially to that portion bordering on 
the cornea, being less marked posteriorly ; the circumference of the eye 
appearing usually quite clear. If the disease is violent, however, and 
passes on unchecked, the vessels of the conjunctiva become enlarged, 
and the whole eye may present a fiery redness. 



582 DISEASES OF THE EYE. 

The cornea is more or less changed in cases in which the inflamma- 
tion extends to the sclerotica, varying from a slight dullness to nebulous 
opacity, and in some rare cases to general opacity, or even ulceration. 

Pain and intolerance of light generally attend in severe cases of iritis. 
The pain is deep-seated, and extends in many cases to the cheek, brow, 
and head, being aggravated during the night. The intolerance of light 
is most marked in cases in which the inflammation extends to the sclero- 
tica, upon which it appears in a great degree to depend. 

A favorable termination of iritis, under judicious treatment, is at- 
tended with a gradual subsidence of the inflammation, absorption of the 
effused lymph, and gradual return of the brilliancy of the iris, and dis- 
appearance of the redness of the eye, as well as a resumption of all its 
functions. 

If, however, iritis be permitted to pass on unchecked, the inflamma- 
tion gradually extends to the sclerotica, choroid, cornea and conjunc- 
tiva. The whole eye becomes more or less involved, the texture and 
color of the iris become more changed, the pupil may become contracted 
and fixed, or lymph may completely close it, there may be atrophy of 
the globe, with fluidity of the vitreous humor, and finally all these de- 
structive changes, with perhaps opacity of the cornea, lead to impair- 
ment of vision, and generally to permanent extinction of sight. 

Diagnosis. — Iritis may be distinguished by the loss of brilliancy and 
change of color of the iris, by the contraction and irregularity of the 
pupil, the pink zone around the cornea, and redness of the sclerotica, 
fading towards the circumference of the eye, the gradual extension of 
the redness to the conjunctiva, and finally by the tendency of the in- 
flammation to involve the different tunics of the eye. But it should be 
remembered, that the change in the appearance of the iris, together with 
the contraction and irregularity of the pupil, is the most important diag- 
nostic feature of this disease. 

Causes. — Iritis may be produced by direct injury, by exposure to 
dampness, dust, heat, &c, and by any cause or train of causes that pro- 
duces other varieties of ophthalmia. I believe, however, that iritis, not 
the result of an extension of inflammation from other tunics or mem- 
branes of the eye, generally depends upon either a hereditary or acquired 
rheumatic, syphilitic, or scrofulous condition of the system. Primary 
iritis then, is generally the result of licentiousness, exposure, want, and 
filth, and in short of the combined influence of every variety and species 
of imprudence that tends to produce or develop a depraved or scrofulous 
condition of the system. 

We have already seen that iritis may be the result of an extension of 
inflammation from other tunics or tissues of the eye, simple as well as of 
a purulent character. 

Prognosis. — The prognosis in recent iritis, if the case be subjected to 
proper treatment, is generally favorable. If, however, the inflammation 
has been active, and the case neglected, so that material change has 
taken place in the structure of the iris, the prognosis is rather unfavor- 
able, especially if there is a very decided rheumatic, syphilitic, or scro- 
fulous condition of the patient. 

Cases of iritis, however, should not be abandoned as hopeless, even 
though very considerable changes have taken place in the iris, as appa- 



EXOPHTHALMIA. 583 

rently desperate cases sometimes recover under the use of proper mea- 
sures judiciously administered. 

Treatment. — The indications in the treatment of iritis are to subdue 
the inflammation and general febrile excitement, when it exists, to arrest 
the effusion of lymph, and promote the absorption of that already effused, 
and finally to promote dilatation of the pupil, and subdue any slight 
irritation that may arise in the conjunctiva. 

In an acute attack of iritis, attended with considerable febrile excite- 
ment, general bleeding should be resorted to, and then cups should be 
applied to the temples or back of the neck, and repeated if necessary. 

In less active cases, attended with little or no fever, general bleeding 
should be omitted, and cups applied and repeated if necessary. After 
general bleeding when it is indicated, and at first, or after cupping, in 
cases in which it is not, a cathartic of calomel should be administered, 
and followed if necessary by half an ounce of the sulphate of magnesia. 

Immediately after the operation of the cathartic, two grains of calomel, 
with four grains of Dover's powder, should be administered every four 
hours, and alternating with this, one-sixth of a grain of tartar emetic 
may be given, and both continued till the inflammation is subdued, or 
slight ptyalism produced. 

A warm foot-bath should be used morning and evening, to lessen the 
cephalic tendency, and promote perspiration. And immediately on the 
suspension of the mercurial, the iodide of potassium should be adminis- 
tered in five grain doses, every six hours, in the syrup, fluid extract, or 
compound decoction of sarsaparilla. 

The tartar emetic should be suspended with the mercurial, and alter- 
nating with the iodide of potassium, four grains of James's powder may 
be given till the inflammation is entirely subdued, when the antimonial 
should be omitted, and the iodide of potassium and sarsaparilla continued, 
three times per day, till the effects of the inflammation are removed, and 
the general condition of the system corrected. A belt about the head 
with eye-pieces wet in an infusion of stramonium should be worn from 
the first, to promote dilatation of the pupil ; and a wash made of one 
drachm of the tincture of stramonium to the ounce of water, should be 
applied to the eyes four times per day, for the same purpose, and should 
the conjunctiva become inflamed or red, the wash may be saturated with 
alum. 

SECTION VII.— EXOPHTHALMIA. 

By exophthalmia, I mean here protrusion of the eyeball, and more es- 
pecially that variety in which it is the direct result of relaxation of the 
muscles of the eye, together with congestion or thickening of the tissues 
back of the eye, constituting the cushion upon which it rests. 

The eye in a healthy state of the system is retained in its place, and 
moved or turned to accommodate vision, by the four recti, and two ob- 
lique muscles, and it rests upon the tissue occupying the posterior part 
of the orbit. It is probable also that the optic nerve tends to retain the 
eye in its place, but it is susceptible of being elongated to a very con- 
siderable extent, as is the case in exophthalmia. 



584 DISEASES OF THE EYE. 

Now the eye is liable to be protruded from various causes, such as 
wounds, tumors, cancer of the eye, or enlargement of the lachrymal 
gland, &c. But such cases belong more especially to the surgeon, and 
need not occupy our time in this place. Exophthalmia occurs, how- 
ever, as I have already suggested, from relaxation of the muscles of the 
eye, together with congestion or thickening of its cushion, or of the pos- 
terior orbital tissues, developing a train of symptoms which we will now 
proceed to consider. 

Symptoms. — This protrusion of the eyeballs, generally occurs in 
debilitated, scrofulous, or anaemic patients, and in very many cases, is 
attended with goitre, and nervous palpitation, and in females with amenor- 
rhcea. 

After a more or less protracted train of symptoms, indicative of poverty 
of the blood, and especially palpitation, with the anaemic murmurs, gene- 
rally arterial and venous, with perhaps congestion or enlargement of 
the thyroid gland, and in females, amenorrhcea, a slight prominence of 
the eyes is noticed. This prominence of the eyes may appear only oc- 
casionally at first, coming on from excitement, or from any cause that 
produces a rush of blood to the head, or hinders a free return of it 
through the veins. Gradually, however, the difficulty increases, till at 
last there is continual protrusion, but still increased at times by the same 
causes that first produced it in its transient form. 

The motion of the eyes may remain nearly or quite natural, but the 
prominence, together with the inability to close the lids, in many cases 
gives them a very unnatural, wild and staring appearance. In one case 
that fell under my care, the protrusion of the eyes was so great at times 
as to render the appearance almost frightful. The appearance during 
the prominent periods was that of very considerable enlargement of the 
globe, but that was merely from the projection of the eyes forwards, as 
was apparent from the natural appearance, as to the size as, the eyes 
passed back to near their normal position, as they did at times at first. 

In another case of a scrofulous character, in which only one eye was 
protruding to such an extent as to make the eye appear very much 
larger than the sound one,-! was satisfied that the appearance of enlarge- 
ment was deceptive, as it proved to be. For as the eye had become 
entirely useless, and as its prominence produced great deformity, it was 
removed, and on examination it was found that the apparent enlarge- 
ment of the globe was from its being pushed forward in the socket, by a 
thickening of the tissues forming the cushion of the eye, in the posterior 
part of the orbit. 

This case was one of long standing, the patient was decidedly scrofu- 
lous, and the loss of sight in the eye, I suspect, was from the change it 
produced in the optic nerve. Generally in cases of exophthalmia of the 
character I have been describing, the sight remains nearly or quite 
natural. 

Such, I believe, are the usual symptoms of exophthalmia from relaxa- 
tion of the muscles of the eye, together with congestion or permanent 
thickening of the tissues forming the cushion of the eye, in the posterior 
part of the orbit, the disease depending upon an anaemic condition, and 
attended, in many cases, with goitre, nervous palpitation, &c, and in 
females with amenorrhea. 



EXOPHTHALMIA. 585 

Diagnosis. — Exophthalmia, of the character I have been describing, 
may be distinguished from cases depending upon tumors, enlargement of 
the lachrymal gland, cancer of the eye, &c, by the attendant symptoms 
of anaemia, nervous palpitation, goitre, and in females of amenorrhcea. 

From enlargement of the eye itself it may be distinguished by the 
attendant symptoms, and also by the variableness of the protusion in the 
early stages, the eye at times, early, occupying nearly its normal position, 
in the variety of exophthalmia I have been describing. 

Causes. — The immediate cause of the protrusion of the eye, in these 
cases, I am confident, as I have already suggested, is relaxation of the 
recti-muscles, together with congestion at first, and in protracted cases, 
permanent thickening of the tissues forming the cushion of the eye in the 
posterior part of the orbit. This relaxation of the muscles of the eye, 
occurs, probably, in the same manner in anaemic patients that relaxation 
of the heart muscle does, in similar conditions, causing dilatation of the 
heart. 

The congestion of the orbital tissues may be the result of a cephalic 
tendency, and imperfect circulation in the extremities, which is a condi- 
tion very likely to prevail in anaemic patients. And the permanent thick- 
ening of these tissues, when it takes place, I believe, is the result of a 
scrofulous condition of the system, the congestion, together with the im- 
perfect state of the absorbents, being the direct cause of it, as well as of 
the enlargement of the thyroid gland, so general an attendant of this 
affection. 

In relation to the remote causes of this affection, it should be remem- 
bered that every influence capable of producing an anaemic condition, 
including every variety of imprudence, may lead to this variety of ex- 
ophthalmia. I believe, however, that in addition to a scrofulous condi- 
tion, excessive losses of blood, protracted masturbation, venereal excesses, 
irregular eating, excessive use of tobacco, and in females, leucorrhoea, and 
amenorrhoea, are by far the most frequent causes which lead to this affec- 
tion. 

Prognosis. — The prognosis in recent cases of this variety of exophthal- 
mia is favorable if the remote causes can be ascertained, the habits of 
the patient corrected, and the general condition of the system restored 
to a healthy state. If, however, the patient is decidedly scrofulous, and 
the case be neglected till a permanent thickening of the- orbital tissues 
takes place, the deformity may continue, the eye never again resuming 
exactly its normal position, and if the protrusion has been very consid- 
erable, permanent loss of sight may result from over tension of the optic 
nerve. 

Treatment. — The habits of the patient should be ascertained and cor- 
rected at once, and great care should be taken that nothing be over- 
looked. Having corrected the habits, the general condition of the 
patient should be ascertained, or the exact deviation from the standard 
of health taken, and then the indications fulfilled by the most convenient, 
safe and reliable remedies. If the bowels are confined, a pill of aloes 
and rhubarb should be taken after dinner each day, and continued till 
they are regulated. The patient should be directed to take a plain, 
digestible and nourishing diet, with strict regularity, should wash the 



586 DISEASES OF THE EAR. 

surface all over, at least twice per week, in moderately tepid water con- 
taining a little salt, and to secure a better performance of the cutaneous 
function, flannel should be worn next the skin. 

A reasonable amount of exercise should be taken, and on no account 
should the patient be exposed to damp impure air. 

If as the general condition of the patient is corrected, the eyes 
gradually sink back to their natural position, small doses of the citrate 
or carbonate of iron may be administered for the blood, and the muriate 
of strychnia in one sixtieth of a grain doses should be given three times 
per day, for a time, to restore if possible the tone of the recti muscles. 
If, however, the exophthalmia continues, indicating thickening of the 
orbital tissues, and the thyroid gland remains enlarged, the iodide of 
potassium should be given in five grain doses three times per day before 
eating, with the hope of removing the thickening of the cushions of the 
eyes, and also the enlargement of the thyroid gland. 

If the patient is anaemic, or if a female, is suffering from amenorrhcea, 
ten drops of the syrup of the iodide of iron should be administered after 
each meal ; and this treatment should be continued with the compound 
iodine ointment to the thyroid gland, if necessary, till the goitre is 
removed, and if possible the eyes restored to their normal position. 
Thus, then, have I completed what I had to say on exophthalmia, and in 
fact, on diseases of the eye. 



CHAPTER XII. 
DISEASES OF THE EAR. 



SECTION I.— GENEKAL OTITIS. 

By general otitis, I mean here a general inflammation of the ear ; all 
the essential parts of the organ, being involved simultaneously, or by 
rapid extension of the inflammation, from one part to another. 

After taking a glance at general otitis, in the present section, I shall 
proceed in the following sections, to consider inflammation of the exter- 
nal, and internal portions of the organ, as well as otorrhea, otalgia, and 
nervous deafness, in the order in which I have named them. 

But before we proceed, it is proper that we should call to mind, the 
general anatomy, and physiology of the ear, that we may proceed un- 
derstandingly. 

The ear, it will be remembered, consists of the pinna, meatus auditorius, 
tympanum, and labyrnith. 

" The pinna is composed of integument, fibj'o-cartilage, ligaments, and 
muscles." The integument is thin, and contains an abundance of seba- 



GENERAL OTITIS. 587 

cious glands; the fibro-cartilage, giving form to the pinna, being closely 
connected with it ; while the ligaments serve to connect the pinna to the 
side of the head. 

The meatus auditorius, is the canal or passage, about an inch in 
length, which extends from the pinna, inwards to the tympanum. It is 
lined by a thin epithelium, and in the substance of its lining membrane, 
are situated ceruminous glands, which secrete the ear wax. Stiff hairs 
also stretch across the passage, to prevent the ingress of insects, and 
other foreign substances. 

The tympanum is an irregular cavity, in the petrous portion of the 
temporal bone, separated externally from the meatus by the membrana 
tympani ; communicating posteriorly with the mastoid eells ; anteriorly 
with the pharynx, by the Eustachian tube, and internally with the 
labyrinth, by the fenestra ovalis, and fenestra rotunda. 

The membrana tympani is concave towards the meatus, and convex 
towards the tympanum, and has an external epidermal layer, a middle, 
fibrous and muscular, and an internal mucus, derived from the lining of 
the tympanum. 

The mastoid cells are numerous, occupying the whole of the mastoid 
process, and part of the petrous portion of the temporal bone. Their 
communication with the posterior circumference of the tympanum, is by 
a large irregular opening. 

The Eustachian tube, extending from the pharynx, to the anterior 
circumference of the tympanum, is partly fibro-cartilaginous, and partly 
osseous; being expanded at its pharyngeal extremity, and narrow, as it 
approaches the tympanum. 

The fenestra ovalis is an oval opening in the upper part of the inner 
wall of the tympanum, nearly opposite the meatus. It is the communi- 
cation between the tympanum and vestibule, being closed by the lining 
membrane of each cavity, to which the foot of the stapes is attached. 

The fenestra rotunda is situated a little below and posterior to the 
fenestra ovalis, and constitutes a communication between the tympanum 
and cochlea, being closed by a membrane over which is reflected the 
lining of both cavities. 

The tympanum is lined by a mucous membrane, and also contains four 
small bones, the malleus, incus, orbiculare and stapes, which are con- 
nected with each other, and so arranged that the handle of the malleus, 
which is attached to the membrana tympani, receives impressions which 
are communicated along the bones to the fenestra ovalis, to which the 
foot of the stapes is connected. 

The labyrinths consist of a membranous and osseous portion. The 
osseous labyrinth consists of the vestibule, semi-circular canals, and 
cochlea, which are cavities in the petrous portion of the temporal bone, 
between the tympanum and the meatus anditorius internus. 

The vestibule is a small cavity situated immediately within the inner 
wall of the tympanum, with which it is connected, as we have already 
seen, by the fenestra ovalis. 

The semi-circular canals are three bony passages communicating with 
the vestibule by both extremities. 

The cochlea forms the anterior portion of the labyrinth, and consists 



588 DISEASES OF THE EAR. 

of an osseous tapering canal, an inch and a half in length, which makes 
two and a half turns around a central axis. The interior of the canal of 
the cochlea is partly divided into two passages, by means of a thin 
lamina of bone. One of these passages terminates in the anterior por- 
tion of the ventricle, while the other opens into the tympanum, by the 
fenestra rotunda, as we have already seen. 

The internal surface of the bony labyrinth is lined by a fibro-serous 
membrane, its internal layer secreting the aqua labyrinthi, "and sending 
a reflection inwards upon the nerves distributed to the membranous laby- 
rinth." 

" The membranous labyrinth is smaller in size, but a perfect counter- 
part with respect to form, of the vestibule and semi-circular canals." It 
consists of a small elongated sac, three semi-circular membranous canals, 
communicating with the first, "and a round sac which occupies the an- 
terior ventricle of the vestibule." The membranous semi-circular canals 
are two-thirds smaller in diameter than the osseous, and are retained in 
their place, as well as other portions of the membranous labyrinth by 
nervous filaments, from openings in the inner wall of the vestibule, 
"and separated from the lining membrane of the labyrinth by the aqua 
labyrinthi." 

The membranous labyrinth is composed of an external serous layer, 
reflected from the lining membrane of the osseous labyrinth, a vascular 
layer, a nervous layer, and finally an internal serous membrane, which 
secretes a limpid fluid, which fills its interior, the liquor Scarpse. It also 
contains two small calcareous masses, the otoconites. 

The auditory nerve, which enters the meatus auditorius internus, 
divides into branches which are distributed to the cochlea, vestibule and 
semi-circular canals, terminating in minute papillae, like those of the re- 
tina. By this delicate nervous expansion, impressions are received 
through the fenestra ovalis and fenestra rotunda, as well as through the 
bony walls of the labyrinth, and communicated to the brain. 

Now, in order to appreciate the symptoms which are developed in 
general otitis, it is necessary to bear in mind not only this general 
anatomy of the ear, but also its general physiology ; at least it should be 
remembered, that the pinna probably favors the concentration and pass- 
age of the waves or vibrations of the atmosphere along the external 
meatus to the membrana tympani. 

The waves, on reaching this membrane, produce an impression upon it 
which is communicated to the handle of the malleus, and thence along 
the incus and stapes to the fenestra ovalis ; and if the Eustachian tube 
is in a state to allow a free circulation of air in the tympanum, a wave 
is also produced in this air, which falls on the fenestra rotunda, or its 
membrane, and also produces a slight impression. 

The impressions thus having reached the labyrinth through the fenestra 
ovale and fenestra rotunda, produce the sensation of sound in the audi- 
tory nerve, by means of the liquid contents of the labyrinth. The sen- 
sation of sound thus produced in the auditory nerve, in its delicate 
expansion, is conveyed along this nerve and the tubular matter of the 
brain, to the gray matter of the hemispheres, and thence to the mind itself. 

The ear thus situated and constituted, is liable to a general inflamma- 



GENERAL OTITIS. 589 

tion, either commencing simultaneously in its different parts, or extend- 
ing rapidly from one part to another. This general inflammation, then, 
is the legitimate subject of the present section, which we will now pro- 
ceed to consider, before taking up diseases of different parts of the ear, 
as I propose to do in the following sections. 

Symptoms. — The symptoms of general otitis vary with the causes 
which produce it. There is generally, however, severe pain extending 
from the pinna to the labyrinth, and often to the whole side of the head, 
attended with throbbing, and perhaps at first with painful acuteness of 
hearing, so that the least sound becomes intolerable. As the disease 
continues, and the meatus auditorius or Eustachian tube becomes closed 
up, the hearing becomes very imperfect ; and if the inflammation passes 
on, and both the meatus and Eustachian tube become closed, the sense 
of hearing may be lost in the affected ear, for the time at least. 

Suppuration may take place along the external meatus; or pus, or 
mucus may accumulate in the tympanum, in which case the membrana 
tympani is liable to be ruptured by the accumulated fluid ; and a more 
or less copious, and perhaps protracted discharge takes place. 

Diagnosis. — General otitis may be distinguished from either external 
or internal otitis, by the extension of the pain to all parts of the ear ; by 
the external signs of inflammation, as heat, redness and swelling ; and 
by the deep-seated pain, throbbing, and either acuteness or dullness of 
hearing, which usually attend if the whole organ becomes involved in 
inflammation. 

Causes. — General otitis may be produced by wounds, irritating injec- 
tions, disease of the brain, electricity, exposure to cold, the extension of 
erysipelas from the scalp, &c. Or it may arise in consequence of 
measles, scarlatina, variola, tonsilitis, syphilis, and during continued or 
typhoid fevers. One of the most severe cases of general otitis that has 
fallen under my observation was produced by a sharp pointed stick, which 
wounded the meatus auditorius ; perforated the membrana tympani ; and 
lacerated to some extent the lining membrane of the tympanum. 

This case was attended with all the symptoms that I have enumerated, 
in their most aggravated form, and it resulted in a permanent loss of 
hearing in the affected ear, as might have been expected. 

Prognosis. — General otitis, if not the result of severe wounds, or a 
complication of some severe or malignant disease, admits of palliation, 
and generally of cure from proper remedial measures judiciously applied. 
If, however, the disease be neglected or improperly treated, the sense of 
hearing may be lost, or in severe cases the inflammation may extend to 
the brain or its meninges, and a fatal termination be the result. 

Treatment. — If the patient is of a full plethoric habit, and the inflam- 
mation is of an active character, general bleeding may be required, and 
when it is, should not be neglected. 

After general bleeding when it is indicated, and at first when it is not, 
cups may be applied to the back of the neck, and leeches about the ear, 
and an active saline cathartic administered. The head should be kept 
elevated ; warm pediluvia should be resorted to ; the bowels should be 
kept loose by small doses of the sulphate of magnesia ; and after the 
leeching, blisters or pustulation with tartar emetic may be resorted to, 
behind the affected ear. 



590 DISEASES OF THE EAR. 

Should suppuration take place, injections of tepid water with a little 
soap should be used to cleanse the meatus, or even the tympanum, should 
the membrana tympani become perforated. Finally, should a chronic 
discharge continue from the ear, after the inflammation is subdued, in- 
jections of five grains of alum, or of the acetate of lead, to the ounce 
of water may be used till it is arrested. 

SECTION II.— EXTERNAL OTITIS. 

By external otitis is here meant inflammation of the pinna, of the 
external auditory canal, or of the membrana tympani, whether one or 
all of these external parts of the ear be involved in the inflammation. 

External otitis may be confined to either of these parts, or it may 
commence in the pinna and extend along the meatus to the membrana 
tympani, or commencing in this membrane it may extend outwards along 
the external meatus to the tissue of the pinna. 

Now the pinna, it will be remembered, consists of integument, fibro- 
cartilage, ligaments and muscles. The tissues forming the external 
meatus, within the bony passage, are the epithelium, the glandular 
structure, the cellular tissue, and periostium. And the membrana tym- 
pani has its three layers, the external epidermal, the middle, fibrous and 
muscular, and the internal mucus derived from the lining of the tym- 
panum. 

The symptoms then, of external otitis vary according as the inflamma- 
tion involves one or all these parts or tissues. We will proceed then to 
examine them as they are developed in cases in which the pinna, meatus, 
or membrana tympani are separately involved, and also as they occur 
in cases in which all these external parts are involved in the inflamma- 
tion. 

Symptoms. — The symptoms in cases of external otitis in which the in- 
flammation is confined to the pinna, are heat, redness, pain, swelling, &c. 
It may be, and very generally is the result of extension of erysipelas from 
the scalp, and in severe cases, suppuration and even ulceration may be 
the result, if the inflammation is allowed to pass on unchecked. 

In cases of external otitis in which the external auditory canal is the 
seat of the inflammation, there is felt at first, an uneasiness along the 
canal, which gradually increases to an itching sensation, and very soon 
to pain, at first slight, but which increases in some cases, to great severity, 
producing a condition bordering on delirium. 

In severe cases the pain is lancinating, and extends to the face, head, 
and neck, and is attended with the most distressing feeling of distension, 
along the auditory canal. Audition is diminished or suspended and the 
pain is greatly increased by pressure, or by motion of the jaw, as in 
eating or speaking. 

The soft tissues of the auditory canal become red, swelled and spongy, 
and nearly or quite fill the passage ; its lining membrane after a day or 
two, being covered with pustules or vesications, or small abscesses appear 
deeper in the cellular tissue. As these vesicles, pustules, or small ab- 
cesses burst, there is a slight alleviation of the pain, and a muco-purulent, 
and often fetid discharge takes place, which may continue for two or 



EXTERNAL OTITIS. 591 

three "weeks, or in case the disease becomes chronic it may continue for 
■weeks or even months. 

In cases of external otitis, in -which the membrana tympani is the seat 
of the inflammation, there is felt at first an acute pain at the bottom of 
the meatus, the result generally of some irritant, followed by a buzzing 
as though an insect were fluttering in the ear. Audition is diminished, 
and the pain is increased by pressure upon the ear, as "well as by loud 
sounds. 

If the membrana tympani be examined with the speculum, it is found 
of a reddish color, and enlarged blood-vessels may often be distinguished 
upon its surface. If, however, the inflammation passes on, the mem- 
brane may become thickened and present a granulated or ragged appear- 
ance. 

From the symptoms which are developed, it is probable that the in- 
flammation commences in the external cuticular membrane, and in severe 
or protracted cases extends to the middle fibrous and muscular layer, in- 
volving, probably, more or less its internal mucous membrane, derived 
from the lining of the tympanum. 

Such, according to my observation, are the ordinary symptoms of ex- 
ternal otitis, as it occurs exclusively in the pinna, auditory canal, or mem- 
brana tympani, in its acute form. More generally, however, external 
otitis commences in the pinna, or meatus, and extends to the membrana 
tympani, combining all the symptoms which I have enumerated as be- 
longing to inflammation of each of these parts, such as pain, redness 
and swelling of the pinna; swelling, pain, and vesication or suppuration 
along the auditory canal, and an itching, buzzing, and painful sensation 
at the bottom of the auditory passage. There is also the muco-purulent 
discharge, as well as the diminution of audition, and perhaps temporary 
deafness of the affected ear. 

Such is external otitis in its acute form. But the inflammation may 
pass on and become chronic ; or it may be chronic from the first. In 
either case, the symptoms being less active, and the progress of the 
disease much slower. The chronic form of the disease is attended with 
little or no febrile excitement, and occurs generally in anaemic patients, 
or in those of a scrofulous diathesis, or from a syphilitic taint. 

Diagnosis. — External otitis may be distinguished from general otitis 
by the absence of the deep seated pain in the ear, mastoid cells, and side 
of the head, by the open and free state of the Eustachian tube, and by 
the milder grade of febrile excitement in external otitis. 

From internal otitis, it may be distinguished by the seat of the pain, 
and also by the redness, swelling, and perhaps suppuration which occurs 
if the pinna or auditory canal, or both, are involved in the inflammation. 

Causes. — External otitis may be produced by wounds of the pinna, 
meatus, or membrana tympani. But I believe it is more frequently, the 
result of a syphilitic taint, or a scrofulous condition of the system ; ex- 
cited perhaps, by the exanthematous fevers, such as rubeola, variola, 
scarlatina, and various forms of putrid diseases. The disease may also 
be produced by the extension of erysipelas from the scalp, and by cold, 
with dampness, as well as by irritating injections into the auditory 
passage. 



592 DISEASES OF THE EAR. 

Prognosis. — The prognosis in recent cases of external otitis, is favora- 
ble, if there is not too much constitutional depravity, and the case be 
subjected to judicious treatment, 

If, however, the constitution is bad, and the case has been neglected, 
the disease may pass on to the chronic form, or if not, serious and per- 
manent changes may occur in the organ, which will materially injure, or 
permanently destroy the function of the affected ear. In most cases of 
otitis, that are subdued for the time, there remains a predisposition in 
the part, to a return of the disease. At least, such has been the result 
of my observation, in such cases, especially in depraved constitutions. 

Treatment. — In acute cases of external otitis, occurring in strong 
plethoric patients, a few ounces of blood may be taken from the arm ; 
but in no other cases. 

After general bleeding, when it is indicated, and at first, in cases in 
which it is not; leeches should be applied about the ear, and if necessary, 
cups to the back of the neck. 

A full dose of the sulphate of magnesia, should be administered, and 
the bowels kept loose, by teaspoonful doses, taken each morning, if 
necessary. The head should be kept elevated, and a warm foot-bath 
should be used at evening, each day. If the pain is intolerable, indicat- 
ing suppuration along the meatus ; a bag of hops, wet in warm vinegar, 
may be bound over the aifected ear, and should it produce relief, it may 
be kept on ; being occasionally moistened, till the inflammation termi- 
nates, by resolution or suppuration. 

If, as suppuration takes place, and a purulent, or muco-purulent dis- 
charge is established, the pain still continues in, or about the ear; blisters 
may be applied back of them, and repeated if necessary; and should the 
disease become chronic, pustulation may be produced by tartar emetic 
ointment. 

Should the vesicles, pustules, or small abscesses along the meatus, be 
well formed, and slow to burst, they may be carefully opened, and the 
auditory passage should be cleansed two or three times per day, by in- 
jections of tepid water, with a little soap, if necessary. 

If the inflammation passes on, and assumes a chronic form, and in all 
cases that are chronic from the first; the general condition of the sys- 
tem should be inquired into, and corrected by proper remedial measures. 
If there is constipation of the bowels, a pill of aloes and rhubarb should 
be given, each day after dinner, till they are regulated. The patient 
should be required to bathe, or wash the surface, at least once each week, 
in water containing a little salt. 

A plain, digestible, and nourishing diet, should be taken, with regu- 
larity; flannel should be worn next the skin, and should there be a 
syphilitic, or scrofulous condition, the iodide of potassium, syrup of the 
iodide of iron, or cod-liver oil may be administered, till the condition is 
corrected. After the general condition is corrected ; if the discharge 
keeps up, five grains of the acetate of lead, may be added to each ounce 
of the water injected into the meatus; and this should be continued, till 
the discharge is arrested. 



INTERNAL OTITIS. 593 



SECTION III.— INTERNAL OTITIS. 



By internal otitis, I mean here inflammation of the mucous lining 
membrane of the tympanum, involving generally the sub-mucous cellular 
tissue, and in some cases the periostium, and extending generally to the 
mastoid cells, Eustachian tube, and more or less to the labyrinth or in- 
ternal ear. 

The mucous membrane of the tympanum as we have already seen, 
besides lining the bony portion of the cavity, forms the inner layer of 
the membrana tympani, and also of the fenestra ovale and rotunda. Im- 
mediately beneath this membrane is the sub-mucous cellular tissue, and 
lining the bony walls of the cavity, is the periostium. It is also neces- 
sary to remember further, that the mastoid cells communicate with the 
tympanum posteriorly, the Eustachian tube anteriorly extending from 
the pharynx, and that the labyrinth lies internally opposite the mem- 
brana tympani. 

Now, we should still further bear in mind the relation of all these 
parts, as well as their structures, or the tissues of which they are com- 
posed, and also the position and functions of the bones of the tympani, 
the malleus, incus, orbicular e, and stapes, in order to appreciate the 
symptoms which are developed in internal otitis, which we will now pro- 
ceed to consider. 

Symjrtoms. — Internal otitis commences with pain deep in the affected 
ear, which gradually extends, till it affects the whole side of the head, 
constituting the most intolerable hemicrania. In violent acute cases, the 
febrile excitement is severe, the eyes are red and watery, and there is 
intolerance of light, the face is flushed, the skin is hot and dry, the pulse 
frequent, and the pain becomes most intolerable in the tympanum, and 
extends more or less through the whole head. 

The pain is increased by deglutition, or by any movement of the jaw, 
as well as by the slightest sounds. " And it extends to the fauces, mas- 
toid cells, labyrinth, and through the brain, being attended often with 
delirium, and finally with deafness of the affected ear. 

On examination, the auditory canal is found free from disease, but if 
matter has collected in the tympanum as is generally the case, it is 
usually discharged by the seventh or eighth day. The matter may es- 
cape by the external meatus through a rupture or ulceration of the mem- 
brana tympani, or through the Eustachian tube, or finally through the 
ulcerated mastoid cells. Generally, however, the matter escapes through 
the external meatus, by a rupture or ulceration of the membrana tympani, 
as the Eustachian tube is generally closed up during the early stage of 
the inflammation, and this membrane is more readily perforated than the 
mastoid process. 

The matter which is discharged is of a muco-purulent character, and 
is apt to be very offensive, and with it the bones of the tympanum are 
often brought away, either through the membrana tympani, or the mas- 
toid process. In case the matter escapes into the throat through the 
Eustachian tube, it is expectorated quite freely, and has a most disagree- 
able taste. 

If the disease is allowed to pass on unchecked, the inflammation may 
38 



594 DISEASES OF THE EAR. 

involve the upper and posterior wall of the tympanum, extend to the 
membranes, and perhaps substance of the brain, and thus the patient 
may be cut down suddenly by meningitis or phrenitis. Or internal otitis 
may pass on and assume a chronic form, or it may have been so from 
the first, in either case the symptoms being the same in kind as those 
already enumerated, but differing in degree, as well as in the progress 
of the disease. 

Chronic cases of internal otitis generally occur in feeble, scrofulous, or 
depraved constitutions, and are apt to be of very protracted duration, 
and attended with a purulent, muco-purulent, mucous, or serous discharge. 
Such I believe are the ordinary symptoms of internal otitis, as it occurs 
in the acute and chronic form, liable of course to variations from pecu- 
liarities of constitution and various accidental causes. 

Diagnosis. — Internal otitis may be distinguished from external otitis, 
by the freedom from disease of the pinna, auditory passage, and perhaps 
of the middle and external layers of the membrana tympani, and also by 
the greater length of time which transpires before the discharge is set 
up. The pain too, in internal otitis is much deeper, effects more generally 
the whole side of the head, and is attended with more marked delirium, 
and general febrile excitement. 

From general otitis it is readily distinguished by the inflammation 
being confined to the tympanum and its appendages, and the internal 
ear, while in the general disease the external parts of the organ are in- 
volved in the inflammation. 

Causes. — Scrofula, a syphilitic taint, and a general depraved condi- 
tion of the system, are the predisposing causes of internal otitis. The 
exciting causes, however, are very numerous, among which are exposure 
to cold and dampness, direct injuries, various exanthematous fevers, as 
measles, scarlatina, smallpox, &c, and other forms of inflammatory, or 
putrid disease. 

Prognosis. — From the liability of serious changes in the membranous 
labyrinth, and the fenestra ovale and rotunda, or their membranes, the 
danger of permanent closure of the Eustachian tube, and loss of the mem- 
brana tympani as well as of the small bones of the tympanum, and 
finally of serious changes in the mastoid cells, the prognosis in internal 
otitis is rather unfavorable. If, however, the case is subjected to proper 
treatment, in season, and before any serious organic change has taken 
place, in essential portions of the organ, reasonable hope may be enter- 
tained of a favorable termination of the case. 

Treatment. — In severe acute cases of internal otitis, occurring in 
plethoric patients, general bleeding should be resorted to at once. Im- 
mediately after general bleeding in cases in which it is indicated, and at 
first in milder forms of the disease in which it is not, leeches should be 
applied about the ear, and cups to the back of the neck, and thus a 
reasonable amount of blood taken. 

A cathartic of calomel or poclophyllin should be administered, and fol- 
lowed by half an ounce of the sulphate of magnesia, and then the bowels 
should be kept loose by small doses of the sulphate of magnesia, admi- 
nistered every morning. The warm foot-bath should be used each eve- 
ning ; and, in severe cases, two grains of calomel may be administered 



OTORRHCEA. ■ 595 

every four hours, commencing after the first cathartic, and continued 
till a slight mercurial impression is produced. 

After the cupping and leeching have been carried as far as is consist- 
ent, blisters should be applied to the back of the neck, and a little later, 
behind the ear. 

Generally, by the sixth or eighth day, matter has collected in the 
tympanum, and in case the Eustachian tube is firmly closed up, it may 
rupture the membrana tympani, and escape by the external meatus. Or 
it may find its way out through the mastoid cells, by destruction of their 
bony walls, the mastoid process, or some point in it. 

Should matter point in the mastoid process, it should be let out at 
once ; and its discharge facilitated, if necessary, by injections of tepid 
water. If it escapes by a rupture, or ulceration of the membrana tym- 
pani, and the matter is thick, or escapes tardily, injections of tepid water 
may be used, cautiously, two or three times per day ; to favor the dis- 
charge of matter, and to cleanse the auditory passage. Should the mat- 
ter from the tympanum escape by the Eustachian tube, it may be favored 
by injections of tepid water, once or twice each day, while the discharge 
continues. 

To inject tepid water into the tympanum through the Eustachian tube, 
the common silver Eustachian catheter, being oiled, should be passed 
along the floor of the nostril, with the convexity upwards, till it reaches 
the pharynx, when it should be gently turned, so that the point shall be 
outwards, and a little upwards, when the instrument may be felt to enter 
the mouth of the tube, along which it may pass for half an inch or more, 
without injury. Having thus introduced the catheter, it should be care- 
fully held in place, and the tepid water may be injected through it, by 
means of a small glass syringe ; and thus the matter in the tympanum 
be diluted, and its discharge facilitated. 

In cases of internal otitis, in which the tympanum becomes filled with 
matter, and it has formed no outlet, the Eustachian tube being closed, a 
jet of tepid water, thus injected, may force a passage to the tympanum, 
and thus the matter be allowed to escape. In case, however, the Eusta- 
chian obstruction is not overcome in this way, rather than allow a rup- 
ture of the membrana tympani, a whalebone sound, slightly enlarged at 
the point, may be passed through the catheter, and carefully pushed 
along till it reaches the tympanum. This being accomplished, the tepid 
water may generally be made to pass, after which the injections may be 
continued while the discharge appears to require it. 

In all cases of internal otitis, that pass on and become chronic, as 
well as such as are chronic from the commencement, the diet, habits, 
and general condition of the patient should be corrected, as well as the 
local inflammation subdued. And when this is accomplished, should the 
discharge from the tympanum continue, five grains of the acetate of lead 
may be added to each ounce of the water injected, and this should be 
continued till it is arrested. 

SECTION IV.— OTORRHCEA. 

By otorrhcea, from w$, "the ear," and p£", "I flow," is here meant a 
discharge of purulent, mucous, serous, or muco-purulent matter from 
the ear, whether derived from the soft tissues of the meatus auditorius 



596 DISEASES OF THE EAR. 

externus, or from the tympanum and its appendages, or from the in- 
ternal ear. 

We have seen in the preceding sections that otorrhoea may be the re- 
sult of inflammation of the structures or tissues of different portions of 
the ear. But as we have already considered the treatment of such cases, 
it remains for us to consider in the present section, otorrhoea as it occurs 
from general and local causes, not of a strictly inflammatory character. 

Such cases may be the result of previous inflammation or irritation, 
but they generally depend upon a scrofulous, syphilitic, or otherwise 
depraved condition of the system, and may be of protracted duration, 
being attended with a train of symptoms which we will now proceed to 
consider. 

Symptoms. — In cases of otorrhoea that follow acute or chronic inflam- 
mation, being kept up after the inflammation is subdued, there remains 
generally a slight uneasiness, or itching sensation in the ear, and audi- 
tion is more or less imperfect, the discharge being evidently kept up by 
a derangement of the structures or tissues that have been inflamed, as 
well as by the depraved condition of the system generally. 

In cases of otorrhoea that have not been preceded by otitis, in addi- 
tion to a general derangement of the system, and especially of the lym- 
phatic and glandular system, there is at first perhaps an itching sensa- 
tion in the auditory passage, Eustachian tube, tympanum, or mastoid 
cells. Sooner or later audition is discovered to be imperfect in the 
affected ear, and in addition to the itching sensation, there is tinnitis 
aurium, and the appearance of the discharge, attended with the uneasi- 
ness which the presence of the matter produces. 

The discharge may be muco- purulent, mucous, or even serous, and 
may vary in quantity from barely enough to moisten the meatus to a 
copious flow, producing considerable inconvenience, and materially im- 
pairing the hearing of the affected organ. The matter generally escapes 
by the external auditory passage. But if it proceeds from the tym- 
panum, and the membrana tympani is imperforated, the matter escapes 
into the fauces by the Eustachian tube, and is expectorated, producing 
a more or less unpleasant taste in the mouth. Or if there has been pre- 
vious disease of the mastoid cells, and the mastoid process has become 
perforated by syphilitic or other disease, the matter may thus escape, 
and be a source of great inconvenience. 

Causes. — Otorrhoea may be the result, as we have already seen, of a 
change in the structure or tissues of the ear, produced by previous in- 
flammation. It is also sometimes the result of inspissated wax, collected 
in the meatus auditorius, as well as of polypi or fingi along the auditory 
canal, or on the membrana tympani. 

Generally, however, it is either the direct or indirect result of a de- 
praved constitution, and especially of a syphilitic or scrofulous condi- 
tion. This, however, may be heightened, and perhaps the discharge 
directly produced by various diseases, among the most frequent of which 
are scarlatina, measles, and the putrid fevers. Otorrhoea may also be 
produced in constitutions predisposed, by improper food, insufficient 
clothing, sleeping in damp apartments, habits of filth, &c, &c. 

Treatment. — In the examination of patients suffering from otorrhoea, 
it is necessary to ascertain the habits and general condition of the patient, 



OTALGIA. 597 

as well as the exact condition of the ear, that the general and local causes 
may be removed as far as possible. 

The patient should be directed to take a plain digestible diet, with 
strict regularity, should sleep in dry apartments, keep the surface of the 
body clean, be properly clad, and, in short, should be made to observe 
strictly the laws of health, and rules of propriety in every respect. 

If there is a syphilitic taint, the iodide of potassium should be given 
in five grain doses, three times per day, in the syrup, fluid extract, or 
compound decoction of sarsaparilla, and continued till the condition is 
corrected, though it take several weeks or even months. 

If the patient is scrofulous, and there is no evidence of a syphilitic 
taint, the bowels and digestive apparatus generally should be placed in 
as good a condition as possible, by proper remedial measures, and then 
ten drop doses of the syrup of the iodide of iron may be given, three 
times per day, before each meal, and an hour after each meal, a table- 
spoonful of cod-liver oil. 

While the general condition of the system is being thus corrected, the 
ear should be kept cleansed by injections of warm water, with a little 
soap, either into the meatus auditorius, Eustachian tube, or into the mas- 
toid cells, if there is, as is sometimes the case, a sinus in the mastoid 
process. This should be done two or three times per day from the first, 
as it serves not only to cleanse the ear, but will also remove any inspis- 
sated wax that may have accumulated in the auditory passage. 

Under this course of general and local treatment, the otorrhcea may 
generally be arrested. If, however, as the general condition of the sys- 
tem becomes thus corrected, the discharge from the ear still continues, 
being kept up by a relaxed or changed condition of the vessels, and other 
soft tissues of the ear, alum, or nitrate of silver, should be added to the 
water injected. At first, ten grains of alum should be added to each 
ounce of the water injected. But, if this fails to arrest the discharge in 
a reasonable time, five grains of the nitrate of silver may be substituted ; 
and this should be continued till the discharge is arrested. 

SECTION V.— OTALGIA— {Ear-ache.) 

By otalgia, from <n>s, "the ear," and cayo?, "pain," I mean here pain 
in the ear from functional derangement of the tympanic nerves, not 
attended with inflammation of any portion of the organ. 

It should be remembered that the tympanum and its appendages are ' 
well supplied with nerves, derived from the facial and other important 
trunks, all of which are liable to functional derangement, attended with 
pain of a strictly neuralgic character. 

Symptoms. — Otalgia may come on suddenly like other neuralgic affec- 
tions, varying in degree from a slight uneasiness to the most acute and 
intolerable pain, of a continuous or intermittent character. The pain is 
generally, I believe, continuous with occasional exacerbations ; during 
which it is apt to extend more or less to the surrounding parts, especially 
along the track of the nerves, involving the face, neck, and other sur- 
rounding parts. Or this disease may assume a strictly intermittent 
character, being quotidian, tertian, quartan, &c, like other forms of 
intermittent disease. 



598 DISEASES OF THE EAR. 

Otalgia may be attended with tinnitus aurium ; more or less intol- 
erance of sound ; and in severe cases with the most distressing delirium. 

Diagnosis. — Otalgia may be distinguished from otitis by the more 
acute and lancinating character of the pain; by the absence of local and 
general inflammatory symptoms ; by the nature of the cause which has 
produced it; and finally by the pain being less continuous, in some cases 
being of a remittent or intermittent character. 

Causes. — Otalgia may be produced by direct irritants ; by exposure to 
cold and dampness ; by the paludal poison ; and by various imprudences 
which produce an anaemic condition, and serve to render the nervous 
system more or less irritable. I believe, however, that otalgia is very 
often produced by carious teeth, tonsilitis, and various other diseases of 
the surrounding parts, as well as by inspissated wax in the meatus 
auditorius externus. 

Treatment. — In cases of otalgia, the causes, whether general or local, 
should be sought out and removed if possible. If a carious tooth is the 
cause, it should be removed ; if tonsilitis, it should be subdued ; and if 
it depends upon disease of any of the surrounding parts, proper mea- 
sures should be used to subdue the primary affections upon which it 
depends. 

If the otalgia depends upon a general anaemic state, and an irritable 
condition of the nervous system, cathartics and then chalybeates should 
be administered. And finally, if it is of an intermittent character, and 
of a malarious origin, a mercurial cathartic should be given with, or 
followed by castor-oil, and then the sulphate of quinine administered as 
for intermittent fever. To soothe the pain, cotton wet with laudanum 
may be passed into the ear, and a fomentation of hops, wet in warm 
vinegar, may be applied to the ear and side of the head. 

SECTION VI.— NERVOUS DEAFNESS. 

By nervous deafness, is here meant, that which arises from functional 
derangement of the acoustic nerve; whether it occurs in plethoric patients 
from a morbid augmented irritability, or in anaemic constitutions, from 
torpor, or diminished irritability of this nerve. 

The labyrinth, it will be remembered, consists of the vestibule, cochlea, 
and semicircular canals; together with the membranous portion, and the 
expansion of the auditory, or acoustic nerve, the aqua labyrinthi, the 
liquor Scarpa, and the two calcareous masses, the otoconites. The audi- 
tory nerve, which we have seen, terminates in a delicate expansion, in 
the labyrinth, is derived from the anterior wall of the fourth ventricle, 
and also receives fibres from the corpus restiforma. It enters the laby- 
rinth through the meatus auditorius internus, and in a healthy condition, 
communicates impressions of sounds, which it receives through the mem- 
branes of the fenestra ovale and rotunda, to the tubular matter of the 
brain, by which it is conveyed to the gray matter of the hemispheres, 
and thence to the mind itself. 

Now any derangement in the function of this nerve, by which it fails 
to heed or take up impressions of sound, communicated to it, or to con- 
vey them to the brain ; from whence they reach the mind, constitutes 
nervous deafness, the symptoms of which, we will now proceed to consider. 



NERVOUS DEAFNESS. 599 

Symptoms. — Nervous deafness may occur in young and plethoric 
patients, or in the aged and debilitated, in the one case, the derangement 
consisting probably, in augmented irritability, and in the other, in di- 
minished irritability, or torpor. 

It is probable, however, that there is diminished sensibility of the 
acoustic nerve in both cases, only it depends upon opposite conditions 
of the parts, and of the system generally. In plethoric patients, it may 
depend upon an active congestion, or the presence of too much blood in 
the nervous expansion, and soft tissues of the labyrinth; while in anaemic 
patients, nervous deafness doubtless arises, from an insufficiency of healthy 
blood in the part, and system generally, to stimulate the nerve into 
healthy activity. 

With this view of the disease under consideration, I shall distinguish 
the two conditions, by the terms plethoric and anaemic, or active and 
passive, as a matter of convenience, and that the real condition, general 
and local, may be kept in mind as we proceed. 

In active or plethoric cases of nervous deafness, in addition to an over- 
plethoric habit, with perhaps a slight congestion of the brain, or derange- 
ment of the digestive, or genital organs; the patient is at first annoyed 
by tinnitus aurium, or sounds in the head, which is compared to the 
buzzing of insects, the roaring of waves, the ringing of bells, &c. 

By degrees, the sense of hearing becomes impaired, and the patient is 
still further annoyed by a more or less constant pulsation in the ears, 
synchronous with the cardiac, which is apt to be augmented by fatigue 
or mental excitement. These unpleasant sensations may at first be expe- 
rienced in only one ear, but they often shift from side to side, and finally 
affect both ears almost constantly. 

The external meatus is apt to be dry in patients suffering from nervous 
deafness ; and in many cases the above symptoms become more marked 
on listening to minute or low sounds, while the patient may hear quite 
well even ordinary conversation, when surrounded by loud noises, such 
as the rattling of carriages, &c. ; which probably serve to rouse the nerve 
into a state of activity, for the time, compatible with audition. 

The ansemic or passive variety of nervous deafness may arise in anae- 
mic patients of all ages ; but it is especially liable to occur in old age, in 
which case it may be very gradual in its approach, the disease continuing 
sometimes for many years before the hearing is entirely lost* 

In this form of nervous deafness, in addition to a general anaemic or 
debilitated condition of the system, there is dryness of the external mea- 
tus, gradual loss of hearing, and in fact all the symptoms which attend 
the active form, except the tinnitus, which does not attend the passive 
form of the disease. 

Such I believe are the usual symptoms of nervous deafness, as it occurs 
in its active and passive form, liable, of course, to variations, depending 
upon the degree of the local and general derangement. 

Diagnosis. — To distinguish cases of nervous deafness from all others, 
a watch should be placed between the teeth, when, if the deafness de- 
pends upon a loss of function in the acoustic nerve, its ticking will not 
be heard by the patient ; but if the deafness is from other causes it will 
be distinctly audible, in consequence of vibrations communicated along 
the cranial bones. 



600 DISEASES OF THE EAR. 

The active variety of nervous deafness may be distinguished from the 
passive by the difference in the general symptoms, already enumerated ; 
and also by the more or less constant tinnitus aurium in active cases, a 
symptom which does not attend the passive variety of the disease. 

Causes. — The active variety of nervous deafness may be produced by 
any cause or train of causes which produces a state of general plethora ; 
some accidental circumstances, such as exposure to loud sounds, &c, 
being the immediate cause of the functional derangement of the acoustic 
nerve. This form of the disease is also frequently sympathetic of de- 
rangement of the digestive or genital organs. 

The passive form of nervous deafness is the direct result of an anaemic 
condition, and is therefore" indirectly produced by every variety of im- 
prudence, which tends to impoverish the blood and debilitate the nervous 
system. It is probable, however, that various local causes sometimes 
operate, either upon the acoustic nerve or brain, to favor the develop- 
ment of this form of disease. It sometimes follows concussion of the 
brain ; and is a frequent attendant of typhus fever, supervening as the 
stage of excitement passes away. 

Prognosis. — The prognosis in cases of nervous deafness is gene- 
rally unfavorable. In recent cases, however, if the causes can be ascer- 
tained and removed, and the general condition of the system corrected 
upon which it depends, the progress of the disease may often be arrested, 
and in some cases the hearing may be restored. 

Treatment. — The indications in the treatment of nervous deafness are 
to remove the causes, to correct the general condition of the system, and 
then if the nervous insensibility remains, to call them into activity by 
suitable general and local measures. The diet, exercise, and general 
habits of the patient should be corrected, and if there are any local causes 
operating they should be removed, as far as possible. If the patient is 
plethoric, and the disease of an active character, a full dose of calomel 
may be administered at first in half an ounce of castor-oil, and a free 
operation secured. The head should be kept slightly elevated and cool, 
and the warm foot-bath used at evening, and for a time, a blue pill may 
be given at evening, and followed in the morning by a teaspoonful of 
the sulphate of magnesia. Cups may be applied to the back of the neck, 
and blisters behind the ears, and repeated if necessary. 

As the general plethora and local congestion is thus gradually overcome, 
the hearing may be restored if the function of the acoustic nerve has not 
been too long impaired or suspended. If, however, when the general 
condition of the patient is thus corrected, the auditory nerve still remains 
insensible, or partially so, the muriate of strychnia may be given for a 
time in ^V of a grain doses, in solution, three times per day, with the 
hope of calling it into activity. 

In cases of nervous deafness of a passive character, occurring in anae- 
mic patients, two or three blue pills may be given at first, and followed 
by half an ounce of castor-oil, after which the bowels should be kept regular 
by a pill of aloes and rhubarb after dinner each day, as long as may be 
necessary. A pill of the ferrocyanuret of iron may be given three times per 
day, after the first cathartic and continued till the blood is restored. If 
the appetite is poor, a cold infusion of columbo, or thirty drops of the 
fluid extract may also be given as long as required. 



RASHES AND ERUPTIONS. 601 

After the general condition of the system has thus been restored, if the 
deafness continues, the muriate of strychnia should be given, as already 
suggested, and continued for a reasonable time, "with the hope of rousing 
the torpid acoustic nerve to the due performance of its function. In case, 
however, the deafness still continues after having corrected the general 
condition, and used the strychnia for a reasonable time, an effort may be 
made to call the torpid nerve into activity by stimulating vapors or in- 
jections passed into the tympanum through the Eustachian tube. 

Various forms of local stimulants may be thus introduced into the 
tympanum, by the Eustachian tube, through the catheter properly in- 
troduced. I believe, however, that the vapor of acetous sether, as used 
by Itard, Kramer, Pilcher and others, will generally do best. 

Into a quart jar, with a wide mouth, containing a pint of warm water, 
and having a cork well fitted, through which is passed a metal or glass 
pipe, having an elastic tube attached to it, furnished with a stop-cock, 
half a drachm of acetous sether may be poured, and the cork imme- 
diately adjusted to the mouth of the jar. This being done to the cathe- 
ter, introduced into the Eustachian tube, the elastic tube with the stop- 
cock should be attached, and thus the vapor be allowed to pass into the 
tympanum. 

The vapor, as suggested by Dr. Pilcher, may be "applied two or three 
times at a sitting," and repeated two or three times per week, as long 
as its effects appear salutary. Finally, should this form of the stimu- 
lant prove insufficient, two drachms of acetous aether may be added to 
a pint of water, and of this small portions may be injected through the 
Eustachian catheter into the tympanum, and repeated daily till a cure 
is effected, or the case becomes hopeless. 



CHAPTER XIII. 
DISEASES OF THE SKIN. 
SECTION I.— RASHES AND ERUPTIONS. 



By rashes and eruptions, I mean here that class of cutaneous disease, 
characterized by some form of rash or eruption. Of the rashes, it em- 
braces red rash, rose rash, and nettle rash, while of the eruptions, it in- 
cludes what I shall call the papular eruptions, vesicular eruptions, pustular 
eruptions, scaly eruptions, animalcular eruptions, and the cryptogamous. 

I design, in the present section, to take a general view of the rashes 
and eruptions, and propose in the following sections of this chapter, to 
take up separately each variety of the rashes and eruptions, in the order 



602 DISEASES OF THE SKIN. 

in which I have named them. But before we proceed to a general con- 
sideration of this class of cutaneous diseases, it is proper that we should 
call to mind the anatomy and physiology of the skin, that we may pro- 
ceed understandingly. 

The skin, it will be remembered, is composed of two layers, the derma 
or cutis, and the epiderma or cuticle. It also contains the sebaceous 
and sudoriparous or perspiratory glands, and is well supplied with arte- 
ries, veins, lymphatics and nerves. 

The epiderma or cuticle is the external layer of the skin, and is a 
product of the derma, which it serves to envelop and defend. Its ex- 
ternal surface is a horny or hard texture, while its internal structure is 
soft and cellular, each layer of which it is composed being less dense, till 
we reach the derma, to which it is attached beneath. The cuticle is per- 
forated by the hairs, absorbent vessels, and by the ducts of the seba- 
ceous and perspiratory glands, and has slight depressions, pits, or fur- 
rows on its inner surface, to receive the papillae of the external surface 
of the cutis, upon which it lies. 

The derma or cutis is the inner layer of the skin, being situated imme- 
diately beneath the cuticle, and is composed of areolo-fibrous tissue, and 
" elastic and contractile fibrous tissue," as well as blood-vessels, lympha- 
tics, and nerves. The areolo-fibrous tissue occupies mainly the inner 
portion of the cutis, as well as the red contractile, and yellow elastic, 
while its external portion, immediately beneath the cuticle, is exceed- 
ingly vascular, and has numerous prominences or papillae. These 
papillae or conical eminences on the outer surface of the derma are, ac- 
cording to Professor Draper, "about f!o tn of an inch in height, and the 
^yo-th of an inch in diameter at their base," subject, however, to varia- 
tions in different situations, or on different parts of the body. These 
papillae contain an elastic substance, and have each a minute artery, 
vein, and sensory nerve. 

The arteries of the derma enter its structure through the areola of its 
inner surface, and divide into innumerable branches, which form a beau- 
ful net-work or capillary plexus in the outer portion of the derma, fur- 
nishing a branch to each of the papilla, which terminate in a minute 
vein. 

The nerves of the derma enter the areola of its inner portion, and 
divide, forming a terminal plexus under its vascular net-work, from which 
fibres pass off as loops in the papillae, as we have already seen. 

The nails and hairs are horny appendages of the skin, the process of 
their formation being identical with that of the formation of the epiderma 
upon the derma, of which they are really a part. 

The sebiparous or sebaceous glands are small, irregular, glandular 
structures, situated in the derma, presenting a variety of complexity, 
some of their ducts emptying into the hair follicles, while others perfo- 
rate the cuticle, and open on its surface. These glands secrete a sebaceous 
or oily material, which probably favors a healthy growth of the hair ; 
and that portion which is emptied on the surface of the cuticle keeps it 
moist and soft, and prevents its peeling off. 

The sudoriparous or perspiratory glands are situated in the deep por- 
tion of the derma, as well as in the subcutaneous areolar tissue, surrounded 



RASHES AND ERUPTIONS. 603 

by adipose cells. They consist of a tube folded on itself, and contained 
in a cell, the walls of which are abundantly supplied with blood-vessels, 
or there may be a collection of sacs, opening into a common efferent 
duct. These ducts of the perspiratory glands ascend through the derma 
and epiderma, passing between the papillae, and terminate on the sur- 
face of the cuticle, in an oblique and funnel-shaped aperture. It has 
been estimated that the number of perspiratory glands and ducts is about 
seven millions ; and, allowing the number of square inches of surface in 
a man of ordinary size to be 2500, it would give an average of 2800 
perspiratory glands and ducts to every square inch of the surface of the 
body. 

The lymphatics of the skin are very numerous, and form a part of the 
vascular net-work in the outer portion of the derma, being interwoven 
with the capillaries and nervous plexus of the skin. 

Now the skin consisting of its several parts has an important function 
to perform, or a variety of functions. Its outer layer, the cuticle or 
epiderma protects the derma or cutis beneath. This in turn covers and 
protects the parts still deeper, and also contains the sebaceous and per- 
spiratory glands as well as the arteries, veins, capillaries, lymphatics and 
nerves of the skin. The capillaries throw off carbonic acid and nitrogen, 
and absorb oxygen, and probably as well as the lymphatics, absorb or 
take in liquid and other substances from the surface of the body. They 
also furnish nutrition, as well as the oily matter secreted by the sebace- 
ous, and the perspirable secreted by the perspiratory glands. 

The sebaceous glands, as we have seen, secrete an oily matter which 
goes in part to the hairs, and in part to the surface of the cuticle, to 
lubricate and keep it soft. 

The sudoriparous or perspiratory glands secrete or separate from the 
blood the perspirable matter, averaging probably about two pounds per 
day, which is conducted to the surface by the seven millions of perspira- 
tory ducts, either as insensible or sensible perspiration. This perspira- 
ble matter thus thrown from the blood, not only relieves the circulating 
fluid of materials no longer useful, but by its evaporation from the sur- 
face of the body, renders latent, and conducts away any excess of animal 
heat, which over exercise, or other influences might cause to be gene- 
rated. 

Finally, the nerves of the skin, serve not only to control the func- 
tions of its different ports, but also being sent to the extreme papillae, 
receive impressions, even of the most delicate character. 

If now we bear in mind the structure and functions of the skin, and 
remember that it is a continuation of the mucous membrane of the inter- 
nal cavities, with which it strongly sympathizes, the rational of the rashes 
and eruptions which we are here to consider, becomes a very plain and 
common sense affair. 

Symptoms. — The general symptoms of the rashes, including the red 
rash, rose rash, and nettle rash, are redness, either diffused or in patches, 
slight swelling, and an itching or burning sensation, attended with little 
or no febrile excitement, the particular symptoms of each variety of 
which I shall notice in the following sections. 

The general symptoms of the eruptions, including the papular erup- 



604 DISEASES OF THE SKIN. 

tions, vesicular eruptions, pustular eruptions, scaly eruptions, animalcu- 
lar eruptions, and the cryptogamous, are slight elevations, either papular, 
vesicular, pustular, scaly, animalcular, or cryptogamous, attended with 
heat, redness, burning, or itching, &c, with little febrile excitement, but 
associated often with symptoms of a deranged or depraved state of the 
solids and fluids of the body. 

Diagnosis. — The simple rashes and eruptions under consideration may 
be distinguished from the exanthematous fevers, which have been con- 
sidered in the early part of this work by their being attended usually 
with less marked general febrile excitement, by their frequent connec- 
tion with habits of filth, and derangement of the digestive organs, and 
finally by their being attended in some cases, with derangement of the 
fluids of the body generally. 

Causes. — The causes of the simple rashes and eruptions are those which 
act directly upon the skin, as filth, direct irritants, improper clothing, 
animals, vegetables, &c. ; those that act through the digestive organs, as 
improper or unwholesome food and drinks, irregular eating, &c. ; and, 
finally, those that act through the system generally, to derange the fluids 
and solids, as putrid articles of food, impure air, and other like in- 
fluences. 

Nature. — Bearing in mind the structure and functions of the skin, as 
well as its sympathetic relations, and the causes which operate to pro- 
duce the rashes and eruptions under consideration, their nature or pa- 
thology become exceedingly plain. 

The rashes, whether the result of a direct irritant, or sympathetic of 
gastro-intestinal irritation, consist in a congestion of the cutaneous capil- 
laries, attended in some cases with inflammation of the dermoid structure, 
either diffused or in patches, and hence the redness, slight swelling, and 
burning or itching which attends ; the cutaneous nerves being involved 
in the irritation. 

The eruptions, whether the result of a local irritant or of a deranged 
or depraved condition of the fluids of the body, consist of an inflamma- 
tion of the dermoid structure, either active or passive ; the elevations in 
the papular variety consisting of enlarged papillse, in the vesicular of a 
watery, and in the pustular of a mattery fluid, poured out under the cuti- 
cle. The scaly eruptions consist of elevations of the cuticle, caused 
directly by disease of the sebaceous glands, or by an obstruction in their 
excretory ducts, in consequence of which the cuticle becomes dry and 
scales off, leaving portions of the derma in a raw and exposed state. 
Finally, the animalcular eruptions consist of slight elevations contain- 
ing matter, the result of the burrowing under the cuticle of a living 
animal ; while the cryptogamous consist of a parasitic vegetable growth, 
&c. 

Now, bearing these facts in mind, and keeping in view the grand divi- 
sion into rashes and eruptions, and the exact condition in the rashes ; 
including red rash, rose rash, and nettle rash, as well as in the eruptions, 
including the papular eruptions, the vesicular eruptions, the pustular 
eruptions, the animalcular eruptions, and the cryptogamous, the general 
indications of treatment are very plain. 

Treatment. — The general indications in the treatment of the rashes 



RED RASH. 605 

and eruptions under consideration, are to remove any local or general 
cause that may be operating, to correct the habits of the patient, to keep 
the skin clean, to correct the general condition of the system, and, 
finally, to destroy any animal or vegetable parasites, if they exist, as 
well as to subdue the congestion, irritation, &c, of the dermoid structure. 

The causes of the cutaneous disease should be sought out at once, and 
removed if possible ; whether it be general or local in its operation. If 
it be the result of filth, impure air, unwholesome or improper food, or 
any other kindred influence, no time should be lost in their removal. 
The patient should be made to conform to the laws of health and rules of 
propriety in every respect, and especially should he be directed to take 
proper food, with regularity, to wear proper clothing, to take sufficient 
exercise, and to' keep the skin clean. 

In a state of health, all persons should wash the surface of the body 
often enough to keep the skin clean, and to keep open the seven millions 
of pores, or perspiratory ducts. The portions exposed to dust, &c, as 
the hands and face, require this ablution at least once every twenty-four 
hours. Other parts less exposed should be washed once or twice each 
week, according to the occupation, exposure, &c. Too much washing 
and fretting the skin, however, increases its filth, by calling to the sur- 
face fluids that ought to be thrown off by the kidneys and bowels, and 
is very apt to produce constipation. If we had been designed by the 
Creator for aquatic animals, we should have been supplied with fins in- 
stead of legs. 

But, while these rules are generally to be followed in health, it must 
be remembered that in various diseases, and in some forms of the rashes, 
and especially of the eruptions, daily ablutions of the whole surface with 
soap and water may be required, to keep the skin clean ; and should by 
no means be neglected. 

Having thus removed the cause, corrected the habits, properly cleaned, 
clothed, and fed the patient, the cutaneous disease may very generally 
disappear. In case, however, the rash or eruption still continues, the 
digestion, if impaired, should be corrected, as far as possible, and any 
impoverished state of the blood or depraved condition of the system re- 
stored, by tonics, alteratives, &c, judiciously administered. 

Finally, when this is all accomplished, as far as may be, if the cutaneous 
disease, whether rash or eruption, still remains, local applications, either 
cooling, soothing, or astringent, &c, may be required, and should be con- 
tinued till a cure is effected. Thus, then, have we completed our general 
view of the rashes and eruptions under consideration, and are now pre- 
pared to take up each variety, in the order in which I have named them. 

SECTION II.— RED RASH. 

By red rash, I mean here those irregular red spots or blotches, which 
appear accidentally upon the skin, from various local or general causes ; 
but generally from some local irritation, as friction or the application of 
an irritant. Under this head w T e may include almost every case of irre- 
gular rash, not connected with the exanthematous fevers, except rose 
rash and nettle rash, which have peculiarities entitling them to separate 
consideration. The chaps which occur on the back of the hands from 



606 DISEASES OF THE SKIN. 

cold, those which occur on the nipples in consequence of nursing, and the 
blotches which occur on the feet of children in the winter season, are 
varieties or specimens of red rash. 

When two surfaces of the skin, moistened by perspiration, or by any 
other fluid, are in such contact that they rub together during the motions 
of the body, the skin becomes red and chafed or inflamed, constituting it 
a case of red rash. 

Red rash is sometimes, however, dependent upon a constitutional 
cause, and associated with derangement of the digestive organs, and 
perhaps with an impoverished state of the blood. In cases of this kind, 
the irregular blotches are apt to appear upon the face, and they may 
come out suddenly and disappear in a few hours, or they may fade from 
the centre, leaving the irregular rash, which has been called ringworm. 

Diagnosis. — To admit any case of irregular rash under this head, it 
is only necessary to ascertain, from the general and local symptoms, that 
it does not belong to any of the exanthematous fevers already considered, 
and also that it has not the bright rose color of rose rash, or the raised 
wheals of urticaria or nettle rash. 

Causes. — The cases of irregular rash which may properly be included 
under this head, have a great variety of causes, most of which act 
directly upon the part to produce congestion, irritation or inflammation 
of the skin, as we have already seen. The general causes, or those that 
act through the system, are also various, among the most frequent of 
which, are improper food, irregular eating, excessive anger, and mental 
excitement. 

Treatment. — In all cases of red rash, the cause should be ascertained 
and removed if possible, and the patient required to take proper food 
with regularity ; to keep the skin clean and warm ; and to take a reason- 
able amount of exercise in the open air. 

The local applications should be judiciously adapted to each particular 
case. If the lower limbs are the seat of the rash, a bandage properly 
applied, may by affording support, be of service in some cases. For 
blotches on the face or other parts, tincture of camphor or a weak solu- 
tion of the sulphate of iron, or of alum, about fifteen grains of either to 
the ounce of water, will do very well as local applications. 

In cases of chaps, galls, &c, the parts should be kept dry and clean ; 
and may be dusted with starch or tannin if necessary, and should this 
fail of affecting a cure, a solution of alum should be applied. In chaps, 
such as occur on the nipples in nursing, and occasionally on other parts, 
an ointment made by mixing intimately a drachm each of tannin and the 
oxide of zinc with an ounce of lard, may be applied three times per day, 
and continued till a cure is effected.* 

' SECTION III.— ROSE RASH— [Roseola.) 

By rose rash or roseola, is here meant that peculiar variety of rash in 
which there are small patches of a rose red color ; which commence on 
the face, and extend over the surface of the body, attended usually with 
slight febrile symptoms. 

Rose rash is usually a slight affection, occasionally attacking young 

* Or a solution of tannin in an ^t of glycerin, may be used. 



ROSE RASH. 607 

children especially while teething, or adults of weekly constitution ; and 
is sometimes associated with constitutional disorders, as rheumatism, 
gout, &c. 

Symptoms. — Rose rash may occur without any noticeable febrile symp- 
toms, but it generally appears after slight gastric disturbance and chilli- 
ness, followed by more or less febrile excitement. 

The rash usually comes out first on the face, neck and breast, and 
gradually over the whole body, or a greater portion of it. Sometimes, 
it has a general diffusion, which with its bright redness, gives it the ap- 
pearance of scarlatina. Generally, however, the rash appears in patches, 
varying from a mere speck to half an inch or more in diameter, and 
being slightly raised, it has considerable resemblance to measles. 

The rash is usually attended with more or less itching or tingling, but 
this is not an invariable symptom. The disease seldom lasts more than 
three or four days, and as the rash disappears, there is very slight, if 
any, desquamation. 

Diagnosis. — Red rash, or roseola, is liable to be confounded with 
measles or scarlatina, from which it may, however, be distinguished by 
attention to the following differences. 

Roseola has not generally so marked constitutional disturbance as 
rubeola or scarlatina, is of shorter duration, and is neither contagious or 
infectious. It has not the catarrhal symptoms of measles, or the an- 
ginose complication of scarlatina. 

Finally, rose rash may be distinguished from red rash by its febrile 
symptoms, by the order which the rash usually observes in making its 
appearance, and by its more regular or uniform character. 

Causes. — Rose rash may appear during various forms of disease, and 
especially in smallpox, vaccina, and varioloid affections, and also in 
bilious and enteric or typhoid fevers. The most common causes of rose 
rash, however, as it occurs during infancy or childhood, are teething, 
and irritation or slight inflammation of the alimentary mucous membrane 
from irregular eating. The most frequent causes of the disease in adults, 
are copious draughts of cold water in hot weather, or when the body is 
heated, fatigue, with mental excitement, and various indigestible articles 
of food. 

Treatment. — The first inquiry after ascertaining the nature of the 
disease should be into the cause or causes that have been operating to 
produce it. If the patient is a child, and taking food at irregular hours 
is the cause, that habit should be corrected, and the child allowed only 
suitable food, to be taken at regular meal hours. If the patient is an 
adult, and in the habit of taking improper or indigestible food, the habit 
should be corrected. Strict cleanliness should be enjoined in all cases. 

During an attack of this disease, attended with little or no febrile ex- 
citement, the patient need only keep quiet, take a plain digestible diet, 
and if there is acidity of the Gtomach and slight constipation, a moderate 
dose of rhubarb and magnesia. In cases, however, in which there is 
considerable febrile excitement, a little mercury with chalk, or blue mass 
may be administered, and followed by the sulphate of magnesia, and 
then moderate doses of James's powder may be given every six hours, 
till the fever subsides. 



608 DISEASES OF THE SKIN, 



SECTION IV.— NETTLE RASH. 



By nettle rash, I mean here, that variety of rash which appears, with 
white elevations or wheals, on a red surface, the elevations appearing on 
any part, from a slight scratch or rubbing, the rash being attended with 
the most intolerable tingling, pricking, or itching; and in most cases, 
with nausea and moderate febrile excitement. 

Symptoms. — Nettle rash or urticaria, may occur from various articles 
of food, and from other causes, without being attended with any considera- 
ble febrile excitement. In such cases, there is experienced at first, an 
uneasiness in the mouth, throat and stomach, followed by epigastric pain, 
nausea, and anxiety, or even coma; and finally, by the eruption. 

The rash in such cases, is apt to be very copious, and is attended in 
some cases, with swelling of the face, neck, and chest, and even the whole 
surface of the body. The elevations or wheals, are scattered here and 
there, and the patient suffers from oppressed breathing, and from the 
most intolerable heat, tingling, and itching on the whole surface of the 
body. In such cases, the severity of the disease continues usually, only 
a few hours, and all the symptoms may disappear in a day or two. 

Among the articles of food, which sometimes thus produce urticaria, 
or nettle rash, in those who are predisposed, are lobsters, oysters, pork, 
eggs, cucumbers, melons, mushroons, &c. Such, according to my ob- 
servation, are the usual symptoms of nettle rash, occurring from various 
articles of food, and attended with little or no febrile excitement. In 
many, and perhaps in the majority of the cases of this disease, however, 
the rash is preceded for two or three days by fever, attended with head- 
ache, nausea, vomiting, faintness, &c. In such cases, the febrile symp- 
toms mostly subside, as the rash makes its appearance, in patches of 
vivid redness, with elevations or wheals rising in the midst of them. 

It may be very extensive, involving most of the surface of the body, 
or it may appear only on particular parts ; as the face, inside of the 
forearm, shoulders, loins, thighs, &c. In cases of this character, the 
rash may partially disappear for a time, during the continuance of the 
disease, and then reappear, till it finally subsides permanently, by the 
seventh or eighth day, after which, a slight desquamation of the cuticle 
may take place. 

I have known urticaria, or nettle rash, to assume even an intermittent 
character ; being associated with, or assuming the character of intermit- 
tent fever. In cases of this character, that have fallen under my obser- 
vation, there has been either a chill, or a tendency to one, during the 
reaction from which, the rash has made its appearance. 

Diagnosis. — Urticaria or nettle rash, may be distinguished from all 
other affections by the wheals or elevations which appear in the patches, 
on different parts of the body, by the excessive burning, stinging, or itch- 
ing sensation which attends the rash, by its non-contagious character, 
and by the general character of the disease, which differs from roseola, 
or the exanthematous fevers, considered in the early part of this work. 

Causes. — Nettle rash may be produced as we have seen by various 
articles of food, in those who are predisposed. It is also produced in 
children by irregularity in taking food, and in adults by imprudence in 



PAPULAR ERUPTIONS. 609 

eating and drinking. The disease is also probably sometimes of malari- 
ous origin, and it may be associated with intermittent or other forms of 
fevers. Certain drugs also occasionally produce it, as turpentine, vale- 
rian, copaiba, &c. 

Nature. — In those cases of nettle rash which occur from various arti- 
cles of food, as oysters, pork, eggs, melons, cucumbers, &c, in which the 
rash makes its appearance in a few hours, without any febrile symptoms, 
I believe that the cutaneous disease is directly sympathetic of irritation 
of the alimentary mucous membrane. In cases in which the rash is pre- 
ceded by marked gastric disturbance, attended by febrile excitement, the 
cutaneous disease is doubtless in part the result of direct sympathy with 
the gastro-intestinal irritation, and also in part produced by the febrile 
excitement, an undue amount of blood being sent to the cutaneous 
vessels. 

Finally the redness of the skin in this disease, as well as in red and 
rose rash, evidently depends directly upon congestion of the cutaneous 
vessels, attended in some cases with inflammation of the dermoid struc- 
ture. The increased heat is probably owing in part to an increased con- 
sumption of oxygen in the cutaneous capillaries, and also in part to the 
suspension of evaporation from the surface, in consequence of the closure 
of the 2,800 perspiratory ducts on each square inch of the surface in- 
volved. 

The itching which attends the rashes, is from the irritation which is 
produced in the cutaneous nerves, while the wheals, which are charac- 
teristic of nettle rash, are the result of a deep congestion of the part, in 
consequence of which the skin is elevated, the pressure beneath forcing 
the blood from the capillaries of the elevated portion, leaving the wheals 
of a whitish appearance in most cases at least. 

Treatment. — Persons that are predisposed to nettle rash, and liable to 
an attack from eating any particular article of food should be careful to 
avoid it. And all persons predisposed to this affection should avoid 
hearty meals, and every variety of indigestible food. In case, however, 
the disease appears, in consequence of over-eating, or of taking indiges- 
tible or improper food, an emetic of ipecac may be given at once, and 
this followed by a cathartic of magnesia and rhubarb, or of the sulphate 
of magnesia. 

This may be sufficient in many cases to arrest the disease. If, how- 
ever, there is febrile excitement, the warm foot-bath, and if necessary 
the warm bath may be resorted to with the hope of restoring the cutane- 
ous function. The patient should be allowed a plain and digestible diet, 
and should the disease assume an intermittent character, in addition to 
what I have already suggested, the sulphate of quinine should be admin- 
istered, as for ague, and thus the disease be arrested. 

SECTION V.— PAPULAR ERUPTIONS. 

By papular eruptions, from papula, a pimple, I mean here that variety 
in which the elevations on the skin consist of dry pimples, sometimes 
retaining the natural color of the skin, but generally red, and attended 
with more or less itching. 
39 



610 DISEASES OF THE SKIN. 

I believe that the papular eruptions generally consist of enlarged and 
inflamed papillae, but they may, in some cases, consist of lymph, effused 
beneath the cuticle, or, in others, of minute points of inflammation of the 
cutis, with congestion of the capillaries of the part, producing the dry 
pimples which arise. 

The papular eruptions might be described under the heads of strophu- 
lus, lichen and prurigo ; but, as it appears to me that such a division, or 
in fact any other, would only " serve to bewilder, and dazzle to blind," 
I shall proceed to the consideration of papular eruptions , as constituting 
but one disease. 

Symptoms. — Papular eruptions, or the dry pimples, may be very 
minute, and, if they retain the natural color of the skin, they may be 
appreciable only by the touch. More generally, however, they are very 
distinct, being more or less deeply colored, according to the degree of 
the cutaneous inflammation, and the condition of the circulating fluids. 
The size of the dry pimples, then, may vary from the merest possible 
elevation of the cuticle, to very distinct pimples, and the color from that 
which is natural to the skin, to a bright red or even livid appearance. 

Itching is another symptom of the papular eruptions, it being in some 
cases slight, but in others so intolerable, as to allow the patient little or 
no rest, day or night. The degree of the itching evidently depends upon 
the amount of irritation in the cutaneous nerves, it being in some cases 
more and in others less. 

The papular eruptions may be extensive, being scattered more or less 
over the whole surface of the body, or the eruptions may appear on par- 
ticular parts, scattered, or in irregular clusters. No age is exempt, as 
the disease may be congenital, or acquired at any period, from early 
infancy to extreme old age. 

Such, I believe, are the ordinary symptoms of the papular eruptions, 
liable of course to variations, from variety of constitution, and from the 
nature of the local or general causes which operate to produce them. 

Diagnosis. — The papular eruptions may be distinguished, on the one 
hand, from the exanthematous fevers, by the absence of febrile excite- 
ment, and on the other, from the vesicular, pustular, scaly, animalcular 
and cryptogamous eruptions, by the dryness of its pimples, while in 
the latter forms of eruptions, the elevations contain a fluid of a watery 
matter, or other character, or else consist of scales or crusts. 

Causes. — Papular eruptions occur during infancy, in part from here- 
ditary predisposition, and also from filth, dentition, and irritation or 
disturbance of the stomach and bowels. 

In adults, papular eruptions may depend upon various local and gene- 
ral causes. I believe, however, that filth, direct irritants, improper food 
and drinks, violent exercise, impure air, insufficient clothing, and mental 
depressions, are the most frequent causes of papular eruptions in adults. 
The disease is also very apt to be associated in adults, with derangement 
of the stomach and bowels, and with an irritable condition of the nervous 
system. 

Nature. — I believe, as I have already suggested, that the papular 
eruptions or dry pimples consist generally of enlarged and inflamed 
papillae, the elevations in such cases being the result of enlargement of 



VESICULAR ERUPTIONS. 611 

the minute artery and vein of which each papilla is composed, the itch- 
ing depending upon the degree of irritation in the loop of nerve which is 
also furnished to each. Doubtless, in such cases, the dermoid capillaries 
are more or less congested, its structure often inflamed, and it is possible 
that the dry pimples may sometimes consist of lymph effused under the 
cuticle, or else of a congestion, with enlargement of the capillaries of the 
part. 

In cases in which the eruption is copious, the functions of the perspi- 
ratory and sebaceous glands are evidently more or less deranged, and 
especially are their ducts obstructed by the enlarged papillae or dry 
pimples, between which they pass to the surface of the skin. 

Treatment. — In the treatment of the papular eruptions, the cause 
should be sought out and removed if possible. The patient should be 
directed to take a proper diet with strict regularity. The clothing 
should be clean, and adapted to the season of the year, being generally 
flannel next the skin in cold, and cotton, linen, or silk in warm weather. 
Sufficient exercise should be taken in the open air to keep up an active 
circulation, without over-heating, and also to secure a healthy action of 
the cutaneous vessels. The skin should be washed in cool or tepid water, 
containing a little salt, at least once or twice each week, and an occa- 
sional warm bath may be of very essential service. Finally an. even and 
cheerful temper of mind should be maintained in all cases of this disease, 
and especially is this of the highest importance in females nursing in- 
fants with papular eruptions. 

Infants affected with this form of eruption should be nursed at regular 
hours, and weaned children should be restricted to their regular meals, 
with no food at intervals. To allay the itching with children, vinegar 
diluted with three parts of water, may be applied occasionally with very 
good effect. For adults, the juice of one lemon, diluted with a pint of 
water, applied two or three times per day, may produce considerable 
relief. 

In very many cases, papular eruptions may be removed by the course 
I have suggested. If, however, the disease is attended with fever, saline 
cathartics may be required. If there is an anaemic state, iron in some 
form should be given for a time. And in cases in which there is a scro- 
fulous or otherwise depraved condition of the system, cod-liver oil, and 
perhaps iodide of potassium and sarsaparilla may be required. 

The cutaneous eruption will generally disappear if the cause is removed, 
and the habits and general condition are thus corrected. If, however, 
the eruption still continues, an application of glycerin with carbonate 
of potassa, about fifteen grains to the ounce, may be applied two or three 
times per day. Or, for adults, three drachms of the potassa may be dis- 
solved in a pint of water, and applied instead, till the eruption is re- 
moved. 

SECTION VI.— VESICULAR ERUPTIONS. 

By vesicular eruptions, I mean here, that variety, in which the eleva- 
tions upon the skin consist of vesicles; a serous or watery fluid being 
poured out under the cuticle, the result of inflammation of the dermoid 
structure, caused by an external or internal cause. 



612 DISEASES OF THE SKIN. 

The vesicular eruptions, or watery elevations in this form of cutaneous 
disease, are formed by the same process of inflammation of the cutis, 
that produces an ordinary blister, the inflamed cutaneous vessels pouring 
out the watery part of their blood, under the cuticle, producing eleva- 
tions or vesicles, varying in size, from the merest point, to vesicles the 
size of a hen's egg, or larger. 

The vesicular eruptions might be described under the heads of eczema, 
herpes, rupia, and pemphigus ; but such a division founded upon the 
size of the vesicles, and in fact any other could be of no practical utility, 
and would only serve to multiply words or names, without in the least 
increasing our knowledge. We will therefore, proceed to the considera- 
tion of vesicular eruptions, as constituting but one disease, thus keeping 
our minds directly upon the pathological condition. 

Symptoms. — With or without apparent constitutional disturbance, the 
vesicular eruptions make their appearance, in vesicles of various sizes, 
from slight elevations, to vesicles of all sizes, up to that of a hen's egg, 
or larger, as we have seen. 

The eruption may be attended with slight fever, and the skin may ap- 
pear red before the vesicles arise. In many cases, however, the disease 
is attended with no febrile excitement, and the skin may appear but 
slightly, if at all red, before the vesicles appear. It is probable, however, 
that the vesicular eruption is generally preceded by either an active or 
passive inflammation of the dermoid structure ; whether it is rendered 
very apparent or not, as there is usually more or less itching. 

The eruption may be quite general, covering most of the surface of 
the body, or it may be confined to a small extent of surface, or to a 
particular part, in either case, the vesicles being scattered or in clusters ; 
depending entirely upon accidental influences. The fluid of the vesicles 
is of a serous or watery appearance at first ; but as they become matured 
in the course of a few days, it may become more or less changed ; assum- 
ing a milky or opaque appearance. And as the vesicles finally burst, or 
become lacerated, it dries and forms a scab or crust, which finally falls 
off; and thus the disease may terminate, if there is no considerable con- 
stitutional disturbance. 

In cases, however, in which there is serious constitutional disturbance, 
new vesicles appear, as the first crop become matured. Or if particular 
care is not taken to keep the surface clean, the watery fluid, on the 
laceration or bursting of the vesicles spreads on the skin, producing an 
irritation, which serves to perpetuate, and extend the disease. Especially 
is this apt to be the case, when the eruption occupies the scalp, produc- 
ing one form of that very unpleasant condition, which has been called 
"scalled head." 

Vesicular eruptions may appear in patches, which extend at the 
same time that the central pustules mature, dry, and desquamate, and 
leave the eruption in a circular form ; constituting what has been called 
"ringworm." Or the eruption may extend half way round the chest, 
constituting what has been called "shingles." These, however, are ac- 
cidental forms of vesicular eruptions, requiring no particular names to 
designate them, and should be included, as well as all irregular forms of 
this disease, under the common name of vesicular eruptions, which point 
directly to the real pathological condition. 



VESICULAR ERUPTIONS. G13 

The duration of a single crop of vesicles to their drying and desqua- 
mation, may vary from five to fifteen days, at which time, if no new 
vesicles have appeared, the disease is at an end. If, however, new crops 
are formed, the disease may be perpetuated indefinitely, and the eruption 
may extend over the whole surface of the body ; and, in depraved con- 
stitutions, the disease may lead on to a fatal termination. 

Such I believe are the ordinary symptoms of vesicular eruptions; 
liable, of course, to variations, from peculiarity of constitution, and from 
various general and local accidental causes, as is the case with all other 
forms of disease. 

Diagnosis. — The simple vesicular eruptions may be distinguished 
from the exanthematous fevers, attended with this form of eruption, 
by the want of the febrile and other attendant symptoms, as well 
as by the non-contagious character of the simple vesicular form of 
eruptions. 

This form of disease may be distinguished from the other varieties of 
simple cutaneous eruptions, by the watery elevations or vesicles ; while 
in the others, the elevations are either dry, pustular, scaly, animalcular, 
or cryptogamous. 

Causes. — The vesicular eruptions are very apt to be associated with a 
hereditary or acquired depraved condition of the system, and especially 
with a partially dissolved or watery state of the blood. Various general 
and local exciting causes, however, operate to produce or develop this 
form of cutaneous disease. 

In infants, this form of eruption may be produced by improper nour- 
ishment, insufficient clothing, filth, impure air, and dentition. In child- 
ren, the very improper habit of taking food at irregular hours or between 
meals ; by impairing digestion ; cutting off nutrition, and thus reducing 
the blood, is one of the most frequent causes of this form of disease. 

In adults, improper food, filth, impure air, intemperance in eating and 
drinking, masturbation and excessive venery, the use of tobacco, mental 
depressions, fatigue, and exposure to the heat of the sun, as well as to 
various local irritants, are, according to my observation, the most fre- 
quent causes of the vesicular eruptions. 

Nature. — The vesicular eruptions are probably in most cases, and per- 
haps invariably, the result of inflammation of the dermoid structures. 
And this cutaneous inflammation may in some cases be of an active cha- 
racter ; but I believe that it is generally decidedly passive ; being asso- 
ciated with a weak, depraved, or watery state of the blood, and hence 
the watery effusion which takes place from the cutaneous capillaries, pro- 
ducing the elevations of the cuticle, constituting the vesicles which are 
formed. 

The size of the vesicles, as well as the extent and form of the erup- 
tion, are entirely accidental, affording no grounds for any practical divi- 
sion of this form of disease, which would call for names, calculated to 
distract and confuse the mind, rather than to point to the real patholo- 
gical condition, which should always be kept in view. 

Treatment. — In all cases of vesicular eruptions, the cause should be 
sought out and removed as far as possible. The patient should then be 
directed to take a proper diet with strict regularity. The surface of the 



614 DISEASES OF THE SKIN. 

body should be washed daily, or sufficiently often to keep it clean, and 
an occasional warm bath should be resorted to. Care should be taken 
that the clothing be of proper material, and that it be kept entirely 
clean. The patient should be directed to sleep in an upper or dry room, 
and to take a reasonable amount of exercise in the open air. 

These preliminaries being arranged, the general condition of the 
system should be corrected, if it is in any way deranged. If there is a 
plethoric condition of the system, and the cutaneous inflammation is of 
an active character, two or three blue pills may be given, and followed 
by a full dose of the sulphate of magnesia, after which, a teaspoonful 
may be given each morning and. continued as long as it may be required. 

If the patient is anaemic, as is very often the case, three blue pills may 
be given at first, and followed by a Seidlitz powder, after which, the 
bowels may be regulated by a pill of aloes and rhubarb taken after 
dinner each day, and continued as long as may be necessary. To 
restore the blood, ten drops of the tincture of chloride of iron should be 
given in a little water, three times per day, and continued till the blood 
is fully restored. When sufficient iron has thus been thrown into the 
blood, if there still remains evidence of derangement of the lymphatic 
and glandular system, five grains of the iodide of potassium may be 
given three times per day, for a time, in an ounce or two of the infusion 
of solanum dulcamara. 

When the cause has been removed, and all the habits as well as the 
general condition of the patient been thus corrected, the eruption will 
generally disappear. In case, however, patches of the vesicles still 
remain, as they may, especially if they have occupied the scalp ; the 
diseased surface should be washed three times per day with weak soap 
suds, and immediately after each washing the parts should be moistened 
with glycerin, containing in solution two drachms of the carbonate of 
potassa to the ounce. 

When the scabs, scales and vesicles are thus removed, as they gene- 
rally will be in three or four days, leaving a greater or less extent of 
raw surface, a cloth wet in a decoction of the root of Phytolacca decandra 
or poke root, of the strength of two ounces to the pint of water, may be 
kept applied to the disease surface till a cure is effected. Or in case the 
eruption occupies some portion of the surface where ihe application of 
the decoction is attended with inconvenience, an ointment made by 
mixing a drachm of the pulverized poke- root with an ounce of lard, may 
be applied three times per day instead, and continued till a cure is 
effected. 

SECTION VII.— PUSTULAR ERUPTIONS. 

By pustular eruptions, I mean here that variety of simple cutaneous 
eruptions in which the elevations of the cuticle are caused by small col- 
lections of pus, the result of inflammation of the derma from a general 
or local cause. 

The pus poured out under the cuticle in this form of cutaneous disease, 
produces elevations of the cuticle in the same manner, that the water or 
serum does in the vesicular form, but the pustules seldom exceed the di- 



PUSTULAR ERUPTIONS. 615 

mensions of a split pea, and are never so minute as some of the vesicles 
in the vesicular form of cutaneous eruptions. 

The pustular eruptions might be described under the heads of ecthyma, 
impetigo, &c, but as there are really no sufficient ground for such divi- 
sion, or in fact any other, I shall dispense with these terms altogether, 
and proceed to the consideration of this form of cutaneous disease, under 
the head of pustular eruptions, the symptoms of which we will now pro- 
ceed to consider. 

Symptoms. — The pustular eruptions are attended with, and generally 
preceded by more or less inflammation of the dermoid structure, and the 
disease may be attended with febrile excitement, but this is by means in- 
variably the case. 

In cases in which the cutaneous inflammation is very considerable, and 
of an active character, the eruption is attended with heat, redness, and 
slight swelling, and in all cases, there is more or less itching, in conse- 
quence of irritation in the cutaneous nerves. The pustules constituting 
this form of eruption, attain their full size, varying from that of a mus- 
tard seed to that of a split pea, in three or four days, and may gradually 
dry up, without bursting; but more generally burst, or are lacerated, and 
then dry, forming a hard crust, which offers a variety of colors, being 
either yellow, brown, or almost black. 

As the first crop of pustules mature and dry, or burst, leaving a scab 
which falls off, the cutaneous disease may subside. But if new pustules 
have formed, the disease may be perpetuated indefinitely, and perhaps 
extend more or less over the surface of the body. When the disease 
occupies the scalp, it is very apt to extend, and continue till the hair is 
lost, constituting one variety of what has been called "scald-head." 

The pustular eruptions are very irregular in their form, sometimes the 
pustules being irregularly scattered over the whole surface of the body, 
and in other cases confined to a very limited extent of surface. Their 
appearance in any definite form, when it occurs, is from purely accidental 
influences, and is a matter of no consequence, as the rule is irregularity, 
and any definite arrangement of the pustules only an exception. 

Some cases of this disease are easily arrested, or may even tend to a 
spontaneous termination. But others are exceedingly obstinate, espe- 
cially if there is considerable constitutional derangement, sometimes pass- 
ing on even to a fatal termination. 

Such I believe are the usual symptoms of the pustular eruptions, liable 
of course to variations, from peculiarity of constitution, and from various 
accidental influences of a general and local character. 

Diagnosis. — The simple pustular eruptions may be distinguished from 
the exanthematous fevers, attended with this form of eruption, by the 
absence or less intensity of the febrile excitement, and by the absence, 
in the simple pustular eruptions, of most of the violent symptoms which 
attend the exanthematous fevers. From the other simple eruptions this 
form may be distinguished by its pustules, while the elevations in the 
other forms are either papular, vesicular, scaly, animalcular or crypto- 
gamous. 

Causes. — A scrofulous, or otherwise depraved condition of the system, 
either inherited or acquired, constitutes a strong predisposition to the 



616 DISEASES OF THE SKIN. 

pustular eruptions. Various local and general causes may, however, 
produce this form of cutaneous disease, or serve to develop it in consti- 
tutions predisposed. Among these causes are local irritants, improper 
food, clothing, filth, &c, intemperance in eating and drinking, gastro- 
intestinal irritation, violent exercise, mental depressions, violent passions, 
sexual excesses, and other kindred imprudences. 

Nature. — We have already seen that the pus, of a yellowish color, 
which produces the elevation of the cuticle in this form of cutaneous dis- 
ease, is the product of inflammation of the dermoid structures. This 
cutaneous inflammation, however, may be of either an active or passive 
character, and is, according to my observation, very often associated with 
a scrofulous or depraved condition of the system. In addition, then, to 
an active or passive inflammation of the skin, with the formation of pus- 
tules, there is evidently in scrofulous cases of pustular eruptions, more 
or less derangement of the cutaneous lymphatics, which complicates the 
cutaneous disease, and perhaps favors the formation of pustules. 

Finally, in common with the other forms of eruptions, there is during 
the continuance of the cutaneous inflammation, in this disease, more or 
less derangement in the functions of the perspiratory and sebaceous 
glands, or at least obstruction in their ducts, which open on the surface 
of the cuticle, and pour out, in a healthy state of the skin, the perspi- 
rable and sebaceous matters. 

Treatment. — The indications in the treatment of the pustular eruptions 
are, to remove the cause, correct the habits of the patient, restore the 
system to a healthy state, and, if necessary, to resort to local applica- 
tions, to favor a restoration of the skin to its normal condition. 

In arriving at the cause, every influence that might be supposed to 
act, either directly or indirectly, should be ascertained and removed, or 
rendered inoperative. 

The patient should be directed to take proper food with strict regu- 
larity, to wear clean and proper clothing, to wash the surface of the 
body daily, or sufficiently often to keep the skin clean, to take a reason- 
able amount of exercise in good fresh air, to preserve an even and cheer- 
ful temper of mind, and to be prudent in all things. 

If the system is phlogistic, three blue pills should be given at first, 
and followed by a full dose of the sulphate of magnesia, and then a tea- 
spoonful may be administered each morning, till the inflammatory ten- 
dency subsides. While this is being accomplished, the warm foot-bath 
may be resorted to at evening, to favor a healthy action of the skin, and 
if convenient, an occasional warm bath may be taken. In case however 
the patient is scrofulous, the iodide of potassium should be given, as 
soon as th3 general inflammatory condition is corrected, in five grain 
doses, three times per day, in the syrup or fluid extract of bittersweet, 
burdock, or sarsaparilla. 

If, however, the patient is anaemic, as is more generally the case, after 
the first cathartic, a pill of aloes and rhubarb may be given after dinner 
each day, if necessary to secure a regular action of the bowels, and after 
having continued the iodide of potassium, &c, for a reasonable time, it 
may be suspended, and ten drops of the syrup of iodide of iron given 
three times per day instead, and continued till the blood is restored. 



SCALY ERUPTIONS. 617 

While this general derangement of the system is being thus corrected 
by the ablutions, cathartics, alteratives and tonics, the cutaneous disease 
will very generally disappear. If, however, patches of the eruption 
remain after the general derangement is corrected, whether on the scalp 
or any other part of the surface of the body, they should be washed clean 
three times per day, and then moistened with glycerin containing in 
solution, two drachms of carbonate of potassa to the ounce, till the scabs are 
removed. This being accomplished, an ointment made by mixing a drachm 
of either poke root, oxide of zinc, tannin or sulphate of iron, with an 
ounce of lard should be applied three times per day, till a cure is affected. 

SECTION VIII.— SCALY ERUPTIONS. 

By -scaly eruptions, I mean here that variety of cutaneous eruptions in 
which the elevations on the skin consist of portions of the cuticle so 
changed as to form scales of various thickness and extent, the result 
generally of cutaneous inflammation. 

While the scaly eruptions are generally the result of cutaneous inflam- 
mation, it should be remembered that an inherited defective formation of 
the cuticle sometimes exists, in which a part or the whole surface of the 
body is covered with scales, and yet there is no evidence of cutaneous 
inflammation, or in fact of any special constitutional disease. Such 
cases, however, two or three of which have fallen under my observation, 
are only exceptions to a rule, as nearly all others I believe are associated 
with, and generally preceded by cutaneous inflammation. 

The scaly eruptions might be described under the heads of psoriasis, 
lepra pityriasis, ichthyosis, $c, but as I can discover no advantage that 
could be derived from such a division, or in fact from any other, I shall 
consider the scaly eruptions as constituting but one disease, the symp- 
toms of which we will now proceed to consider. 

Symptoms. — The appearance of the scaly eruptions is generally pre- 
ceded by more or less evidence of irritation and inflammation of the skin, 
such as heat, dryness, itching and redness. At the inflamed points in 
the skin, slight elevations occur, in some cases, on which the scales 
gradually form, with either a smooth surface, or having a slight depres- 
sion in the centre, the scales gradually thickening, and finally becoming 
detached and falling off. 

In other cases, the elevations are very slight, the scales being of a 
minute branny character, and coming off in countless numbers, to be fol- 
lowed by others. Or, a part, or the whole surface of the skin may be 
covered with a thick and hardened scale divided only by the natural 
furrows of the skin, the scales being little disposed to exfoliate, and being 
quickly replaced if removed. Such cases are attended with little or no 
cutaneous inflammation, and may be either congenital or acquired. 

The size of the scales then, in the scaly eruptions, may vary from those 
of a minute branny character, which have been called dandruf, to those 
that cover the whole surface, being divided only by the natural furrows 
of the skin. The scaly eruptions may be confined to a very limited extent 
of surface, or they may extend indefinitely, covering, in some cases, as 
we have seen, the whole surface of the body. 



618 DISEASES OE THE SKIN. 

No age is exempt, and when the eruptions have once made their ap- 
pearance, whatever may be their form or extent, the disease is apt to be 
obstinate, or of protracted duration. 

Though this variety of cutaneous disease is not usually attended with 
very severe itching, there is, in almost every case, an uneasiness experi- 
enced in the diseased part, which is exceedingly annoying, especially if 
the scalp is the seat of the eruption. 

Such, I believe, are the ordinary symptoms of the scaly eruptions, the 
variations being accidental, depending upon peculiarity of constitution, 
and other accidental circumstances. 

Diagnosis. — The scaly eruptions may be distinguished from other cuta- 
neous eruptions by the scaly character of the disease, the cutaneous 
elevations consisting of changed and perhaps thickened cuticle, without 
the previous formation of pimples, vesicles, or pustules as is the case in the 
other forms of eruptive cutaneous disease. There is no other form of 
disease with which the scaly eruptions need be confounded, if all the 
symptoms be carefully taken into account. 

Causes. — Various causes operate to produce the scaly eruptions, either 
predisposing or exciting, among which are improper varieties of food, 
and irregularity in taking it, depressing or very exciting mental emo- 
tions, direct irritants, exposure to the heat of the sun, or to very hot 
fires, and intemperance in eating, as well as in the use of alcoholic drinks. 

In congenital cases, two of which I have known in one family, the 
cause or causes which operate, are obscure, or at least are so to me, as 
both parents were apparently free from any disease of the kind, in these 
cases. It is probable, however, that some peculiarity of constitution, or 
habits on the part of the parents ; or some influence of the locality, or 
some peculiar mental emotion endured by the mother, during gestation, 
may operate to produce the disease in the offspring, or a predisposition 
to it, at least. 

Congenital cases, however, are very rare, and yet I believe, that a 
hereditary predisposition to the cutaneous eruptions may prevail, in most 
cases in which the disease is developed, in infancy or early childhood, 
and perhaps in some cases in which the disease is developed later in life, 
by the exciting causes enumerated above. 

Nature. — In relation to the nature of the scaly eruptions, it appears 
to me, there can be no reasonable doubt. The elevations or scales, what- 
ever may be their size, from the branny scales, to those which cover the 
whole surface of the body; being divided only by the natural furrows of 
the skin, consist of changed or imperfectly formed cuticle, which gradu- 
ally become detached, and fall off; their place being generally very soon 
supplied by others of a like, or similar character. 

The portions of changed, or imperfectly formed cuticle, constituting 
the scales, in this form of eruption, are sometimes thickened, and always 
dry and hard, indicating a failure on the part of the sebaceous glands, 
to furnish sufficient oily matter to the diseased portion of cuticle, to keep 
it soft. In consequence of this, the cuticle becomes thus hardened, and 
sometimes thickened, and generally exfoliates. 

In congenital cases, I believe that there is a permanent defect in the 
function, and probably in the structure of these oil glands of the skin, 



SCALY ERUPTIONS. 6l9 

which produce this form of cutaneous disease. In all other cases of the 
scaly eruptions, or in most of them at least, it is probable that inflam- 
mation of the derma, of either an active or passive character; involving 
the sebaceous glands, or their excretory duct, either suspends the secre- 
tion of the oily matter by the glands, or stops its passage through their 
excretory ducts, to the surface of the cuticle, in the diseased portions of 
the skin. 

Treatment. — With the real nature of this form of disease thus in view, 
and unburdened of a multitude of names, which could only bewilder, the 
indications in the treatment of the scaly eruptions, are very plain. 

In all cases of the scaly eruptions, the habits of the patient should be 
inquired into, and corrected. 

The patient should be directed to take proper food, with strict regu- 
larity; to wear clean and suitable clothing; to take a reasonable amount 
of exercise in the open air; to keep the surface of the body clean, by 
daily ablutions, or the warm bath, if necessary; to preserve an even and 
cheerful temper of mind, and finally, to observe strictly, the laws of 
health, and rules of propriety in every respect. 

In congenital cases, nothing more than this need be done, unless the 
scales become so hard at certain points as to injure or irritate the 
derma, in which case it may be partially softened by the application of 
glycerin, morning and evening, till the irritation subsides. A perma- 
nent cure of such cases need not be anticipated, and therefore should 
not be attempted. 

In all other cases of scaly eruptions, however, an effort should be made 
to cure the disease. If the patient is plethoric, and the cutaneous in- 
flammation of an active character, three blue bills, or a full dose of lep- 
tandrin or podophyllin should be administered at first, and followed, if 
necessary, by the sulphate of magnesia, to secure a free operation. 
After the first cathartic, a Seidlitz powder may be given, each morning, 
till the phlogistic condition is overcome ; a warm foot-bath being used at 
evening, if necessary, as well as the daily ablutions, or use of the warm 
bath. 

If, however, the patient is anaemic, after the first cathartic, the infu- 
sion or fluid extract of taraxacum may be administered, for a time, as 
an alterative, and for the purpose of regulating the bowels. As soon as 
the bowels are thus regulated, ten drops of the syrup of the iodide of 
iron may be given, three times per day, in a drachm of the fluid extract, 
half an ounce of the syrup, or two ounces of the infusion of burdock, or 
of the solanum dulcamara. When sufficient iron has thus been thrown 
into the blood, it may be suspended, and, if the patient is scrofulous, the 
burdock or bittersweet may be continued, with five grains of iodide of 
potassium, three times per day, till the general condition is corrected, as 
far as it may be. 

While this general treatment is being pursued, nothing should be done 
locally, except to continue the daily ablutions, or use of the warm bath, 
and to apply to the diseased part sufficient glycerin to soften the cuticle, 
till such time as the sebaceous glands shall resume their functions, and 
thus put an end to the cutaneous disease. Finally, as the general con- 
dition of the system becomes corrected, if the scaly eruption continues, 



620 DISEASES OF THE SKIN. 

a drachm of the oxide of zinc may be mixed with each ounce of the gly- 
cerin applied, and continued till a healthy state of the skin is restored. 

SECTION IX.— ANIMALCULAR ERUPTIONS. 

By animalcular eruptions, I mean those which occur from the burrow- 
ing or presence of living animals in the skin, or under the cuticle, the 
most common and interesting of which is the " acarus scribiei" or, as it 
has recently been called, the " sarcoptes hominis." 

The disease of the skin caused by this animal has been called " itch;" 
but as the other forms of cutaneous eruptions, or some of them at least, 
are attended with severe itching, I can see no reason why this term 
should be applied to this form of eruption any more than to others. I 
shall therefore consider this form of cutaneous disease, in common with 
others of an animalcular character, under the head of animalcular erup- 
tions ; the symptoms of which we will now proceed to consider. 

Symptoms. — The first symptoms of the animalcular eruptions are itch- 
ing in some portion of the skin, and very soon slight redness, either in a 
point or lines of very limited extent, caused by the burrowing of a minute 
animal. 

The burrows gradually extend, till they pass through a considerable 
extent of the cuticular surface, the cuticle always assuming a rough or 
ragged appearance, as far as the disease extends. 

The itching and red points or streaks in the skin, together with the 
ragged appearance of the cuticle, extending gradually over the surface 
of the body, and appearing especially conspicuous between the fingers, 
at the flexures of the joints, and at points generally where the cuticle is 
most delicate, together with the appearance of the animal, when discover- 
able, constitute the only invariable symptoms of the animalcular erup- 
tions. 

In many, and perhaps in most cases of the animalcular eruptions, how- 
ever, small elevations of the cuticle appear, containing either a watery 
or mattery fluid, near which the parasitic animal may often be seen in 
the form of a small white or brown speck, barely visible to the naked 
eye. These elevations are often torn by scratching, and then present 
open sores, which finally scab, desquamate and heal, and perhaps give 
place to others, but not generally I believe. 

The animalcular eruptions may continue for months, or even years, if 
the parasitic animal, the burrowing of which produces them, is allowed 
to continue his operations unmolested. And though the disease must 
be attended with great inconvenience, it seldom tends to a fatal termina- 
tion. 

Such are the ordinary symptoms of the animalcular eruptions, liable 
to variations depending upon the extent and duration of the disease, and 
also upon the habits of the patient, and perhaps upon the character of 
the animal which has produced them. 

Causes. — The causes of the animalcular eruptions are the parasitic 
animals, by far the most common of which is the acarus scabiei, or sar- 
coptes hominis, as we have already seen. The presence of the parasitic 
animals alone are sufficient to produce this form of cutaneous disease. 



CRYPTOGAMOUS ERUPTIONS. 621 

But a dirty skin, with filthy habits generally constitute a strong predis- 
posing cause, and probably tends materially to perpetuate this form of 
disease. 

The parasitic animals may be taken by contact with persons on whom 
they dwell, from cloths which they have worn, or from beds in which 
they have slept. And if they find their new subject filthy, and a stranger 
to soap, they will multiply rapidly, and very soon cause to be developed 
the eruption which they produce. 

Diagnosis. — The animalcular eruptions may be distinguished from all 
other eruptions, by the intensity of the itching, even when there is only 
the slight red points or streaks in the skin, with a rough or ragged ap- 
pearance of the cuticle, while in other varieties of cutaneous eruptions, 
the itching is in proportion to the intensity of the cutaneous inflamma- 
tion. In addition to this, the parasitic animal, when discoverable, con- 
stitutes positive diagnostic symptoms. 

Treatment. — The indications of treatment in the animalcular erup- 
tions, are to restore the skin to a cleanly state, by proper ablutions, and 
then if the parasitic animal is not routed, or destroyed, to apply to the 
affected portions, or if necessary to the whole surface of the body, a 
poison to the parasite, which is at the same time harmless and soothing 
to the skin of the patient. 

In all cases of animalcular eruptions the patient should be directed to 
wash the whole surface of the body daily, with strong soap-suds, to wear 
clean and proper clothing, and to observe cleanly habits, in every re- 
spect. This alone may destroy the parasitic animal in a few days, in 
many cases. If not, and the eruption is of limited extent, the mercurial 
ointment, or an ointment made by mixing two drachms of iodide of 
potassium with an ounce of lard, may be applied to the diseased surface, 
after each daily ablution, and continued till the parasitic intruders are 
destroyed, and a healthy state of the skin restored. 

In cases, however, in which the eruption is very general, the animals 
having multiplied, and colonized more or less extensively, nearly every 
portion of the cutaneous surface, as is apt to be the case with the acarus 
scabiei, or sarcoptes hominis, either the sulphur vapor baths should be re- 
sorted to for a few evenings, or the sulphur ointment should be applied. 

If the sulphur vapor baths are at hand, one may be taken after each 
daily ablution with soap and water, till a cure is effected. If not, the 
sulphur ointment, made by mixing one part of sulphur with two of lard, 
may be applied to the whole surface of the body, each evening, after the 
washing with soap and water, clean clothes and bed clothes being sup- 
plied each day, and this should be continued till the cure is effected. 

SECTION X.— CRYPTOGAMOUS ERUPTIONS. 

By cryptogamous eruptions, from x^vtho^ " concealed," and ya^oj, "mar- 
riage,"* I mean here that variety of cutaneous eruptions in which the 
elevations on the skin consist of minute cryptogamous parasitic vege- 
tables, the result of the germination of sporules lodged about the roots 

* Plants whose stamens and pistils are concealed or not manifest, their sex being un- 
known. 



622 DISEASES OF THE SKIN. 

of the hairs, in abrasions of the cuticle, or else in filth, constituting a 
soil upon its surface. 

The crjptogamous eruptions may occupy any part of the cutaneous 
surface, but their most frequent seat is in the beardy portions of the 
face, and upon the hairy scalp, probably in consequence of the facilities 
offered by the hairs for the lodgment of the sporules, from the germina- 
tion of which, the plants constituting the eruption are produced. 

The cryptogamous eruptions might be described under the heads of 
sycosis, favus, trichosis, &c, but as these terms would serve rather to call 
off the mind from the real pathological condition to accidental appear- 
ances I prefer to dispense with them altogether, and to consider this 
form of disease as one, under the head of cryptogamous eruptions, the 
symptoms of which we will now proceed to consider. 

Symptoms. — The cryptogamous eruptions, as we have already seen, 
may make their appearance on any portion of the cutaneous surface, but 
generally either upon the beardy portions of the face or the hairy scalp. 

There is generally at first an itching sensation experienced in the part, 
and soon slight yellow elevations, commencing usually about the roots or 
the hairs, attended with heat, pain and redness. These elevations, whether 
on the face or scalp, may be isolated, or in clusters, and they may occur 
over quite an extent of surface at first, or they may commence at a single 
point, and extend in different directions, according as one or more 
sporules, seeds, or germinating principles have been lodged, from which 
the crop of parasitic vegetables are to be produced. If the disease oc- 
cupies the face, the germination of the sporules and growth of the 
vegetables which they produce, together with the accidental irritation to 
which the face is liable, are apt to cause considerable inflammation of 
the skin. In such cases, the elevations increase in part from the growth 
of the parasite, and in part from the inflammation of the skin which they 
produce. And if the cutaneous inflammation is intense, the elevations 
instead of spreading out in crusts with pits or depressions, as is common 
in this disease, may contain a little matter, burst in five or six days, and 
then form crusts, between which small pustules and tubercles may appear. 

More generally, however, if the disease occupies the scalp, or even the 
face, if the inflammation is slight, the elevations consisting of the germi- 
nating vegetable parasite and epidermic scales, and having the appear- 
ance at first of yellow specks about the roots of the hairs, gradually 
spring up and spread out in the form of crusts, with small pits or depres- 
sions in the centre. In such cases, the inflammation of the derma is less, 
and consequently no pustules or tubercles appear between the crusts. 

The sporules as we have seen generally lodge about the hairs, or in 
the hair follicles, the vegetables which they produce usually springing 
from that source. This, however, is not the only seat of the parasites, 
for a slight abrasion of the cuticle, or even a layer of dirt upon its sur- 
face, may afford ground for the lodging, germination, and springing forth 
into a vegetable of the sporule which may chance to float that way. 

These vegetable crusts may be isolated at first, and they may occupy 
but a small extent of surface of the face or scalp, or of other parts where 
they may appear. Gradually, however, the eruption extends, and as 
the parasitic vegetable crusts increase in thickness and circumference, 



CRYPTOGAMOUS ERUPTIONS. (323 

they may meet, forming finally a complete crust over the affected part, 
with pits or depressions, which has been thought to give the eruption the 
appearance of a honeycomb. 

If, however, the disease is permitted to continue, as it is sometimes for 
months, or even years, the surface of the crusts gradually crumble off 
presenting an irregular appearance. Or portions of the crusts may des- 
quamate, or be torn off, to give place to others of a similar character, 
which spring up and shoot forth with great luxuriance. 

When the cryptogamous eruptions appear upon the face, then con- 
stituting what has been called sycosis, the inflammation of the derma is 
apt to be very considerable, causing small vesicles and tubercles to ap- 
pear between the parasitic vegetable scales. The disease in such cases, 
if neglected becomes exceedingly troublesome, involving not unfrequently 
the whole bearded portion of the face. 

In cases, however, in which the cryptogamous eruptions appear upon 
the hairy scalp, constituting what has been called favus, the parts are 
less liable to be irritated, and consequently the derma is not usually so 
intensely inflamed. As a consequence of this, the sporules germinate 
shoot forth, and in many cases form crusts which cover the whole head, 
without the intervention of pustules, or tubercles which the intensity of 
the inflammation when the face is its seat, is so liable to produce. 

The cryptogamous eruptions, if long continued, are very apt to be 
attended with a loss or falling of the hair, and especially is this the case 
in those cases which have been called trichosis, in which parasitic cryp- 
togamous growths appear, when examined microscopically, in the interior 
of the hairs on the diseased surface. 

Such I believe are the ordinary symptoms of the cryptogamous erup- 
tions, with their principal variations, depending upon the seat and dura- 
tion of the disease, and other accidental circumstances. 

Diagnosis. — The cryptogamous eruptions may be distinguished from 
all others, by their preference for the bearded portions of the face and 
hairy scalp, by the peculiar yellow appearance of the elevations at first, 
being developed into crusts with pits or depressions as the disease pro- 
gresses, and rather disposed to crumble than desquamate, and finally by 
the appearance, when examined by the microscope, of some variety of 
cryptogamous parasitic plants. 

In those cases of this disease, in which the intensity of the cutaneous 
inflammation causes the appearance of the eruption to be rendered irre- 
gular, by the development of pustules and tubercles between the irregular 
crusts, the microscopic plants, when discoverable, renders the diagnosis 
clear, notwithstanding the irregularity. 

Causes. — The direct cause of the cryptogamous eruptions is the lodg- 
ment, either about the hairs, in fissures of the cuticle, or else in a layer 
of dirt upon its surface, of the sporules of some form of cryptogamous 
parasitic vegetables, and their germination and development into a ma- 
ture plant. It is probable, however, that various causes predispose the 
system to this form of disease, among which are all the debilitating 
agents and influences, by lessening the powers of vital resistance, and 
also filth or dirt upon the skin, which not only affords facilities for the 
lodgment of the sporules, but also constitutes a soil in which they may 
conveniently germinate, and be developed into mature plants, 



624 DISEASES OF THE SKIN. 

A few of the parasitic plants which produce the cryptogamous erup- 
tions have been examined, described, and named. But it is sufficient for 
our purpose here to remember that the crust, in this form of eruption, 
consists of a cup-shaped capsule, having a cavity within ; the walls con- 
sisting of epidermic scales, while the internal part consists of the para- 
sitic plant, with its sporules and other parts variously developed. 

It is probable that the sporules of the cryptogamous plants, may be 
taken from the air, in which they doubtless float, as well as from the 
bodies of those upon whom the plants which produce them are flourishing. 

Nature. — The cryptogamous eruptions, are evidently the result of the 
germination, and growth of the different varieties of the parasitic crypto- 
gamous plants, the sporules of which have been taken from the air, in 
which they float, or else from the bodies of persons on which the plants 
grow, by combs, hats, clothes, &c. 

The sporules, as we have seen, more generally lodge about the roots of 
the hairs, in the follicles of which they often germinate, and take root. 
Sometimes, however, they lodge in abrasions of the cuticle, or in a layer 
of dirt upon its surface. 

The elevations in this disease, are the parasitic plants, together with 
portions of the cuticle, and in cases in which the derma, and tissues be- 
neath are highly inflamed, as we often see, when the face is the seat of 
the disease, the elevations often assume a pustular appearance, before 
the crusts form, and interspersed with the crusts, pustules and tubercles 
often appear, as might be expected. 

I believe, that in a perfect state of health, if cleanliness be observed, 
the liability of contracting this disease is very slight, as the powers of 
vital resistance are such, that if the sporules are brought in contact with 
the skin, they will seldom germinate, and produce the parasitic plant. 

On the other hand, in persons of feeble or depraved constitutions, if 
the skin is covered with dirt, as is too often the case, the predisposition 
is very strong, as the sporules not only readily find a lodgment ; but they 
find a soil in which they may germinate, and thrive with great luxuriance. 
Hence it is that the cryptogamous eruptions most frequently appear on 
persons of feeble or depraved constitutions, and especially on those of im- 
prudent filthy habits. 

Treatment. — The indications in the treatment of the cryptogamous 
eruptions, are to correct the habits, and general condition of the patient ; 
to apply to the diseased surface, a remedy which shall remove the crusts, 
and then something to the raw surface, which shall destroy the roots of 
the parasites, and at the same time, favor the formation of a healthy 
cuticle. 

The patient should be required to take proper food, with strict regu- 
larity ; to wear suitable and clean clothing ; to take sufficient exercise ; 
to sleep in dry apartments; to wash the whole surface of the body once 
each day, with soap and water, and to observe the laws of health, and 
rules of propriety in every respect. 

When these preliminaries have been arranged, the local treatment 
should be commenced at once, and if the patient is scrofulous and anaemic 
the iodide of potassium or syrup of the iodide of iron should be given in 
moderate doses, that the general condition may be corrected, as well as 
the local disease removed. 



CRYPTOGAMOUS ERUPTIONS. 625 

Now to remove fungoid elevations or crusts, various remedies may be 
resorted to ; but that which I have found the most speedy and safe, is 
glycerin containing in solution two drachms of carbonate of potassa to 
the ounce. The affected surface should be washed morning and evening 
with soap and water, and immediately after the washing, the crusts 
should be moistened with the glycerin and the potassa ; and this should 
be continued till the crusts are removed, the head, if the disease be of the 
scalp, being covered with an oil-silk cap. I have succeeded in removing 
the crusts in three or four days in this way, the hair, if the disease 
occupies the scalp, sometimes coming off with it, if it had not previously 
fallen, and a portion of the beard, if the disease is of the face, leaving in 
either case a raw surface. 

Now having thus removed the crusts, to destroy the roots of the cryp- 
togamous parasitic plants, and to favor the formation of a healthy cuticle, 
it is only necessary to keep the raw surface covered with cloths wet in a 
decoction of the phytolacca decandra or poke root ; made from two 
ounces of the root to the pint of water. Or if the disease occupies the 
face, or any portion of the surface away from the scalp, where the con- 
stant application of the decoction is inconvenient, an ointment made by 
mixing two drachms of the pulverized 'poke root with an ounce of lard, 
may be applied to the raw surface, instead, three times per day, and con- 
tinued till a healthy cuticle is formed and the disease permanently cured. 
I have succeeded thus in permanently curing cases of the cryptogamous 
eruptions on the scalp, face and other portions of the surface in from 
two or three weeks ; and I believe it need seldom take a longer time 
than that. 

When the treatment is commenced, combs, hats, brushes, cloths, &c, 
should be changed, and when a cure is effected, these in turn should be 
laid aside and an entire new set substituted, that a return of the disease 
may be prevented. 

Thus have I completed what I had to say on the simple rashes and 
eruptions, including among the rashes, red rash, rose rash and nettle 
rash ; and among the eruptions, papular eruptions, vesicular eruptions, 
pustular eruptions, scaly eruptions, animalcular eruptions, and the cryp- 
togamous. By thus dispensing with all terms except those which point 
directly to the pathological condition, and treating each case on strictly 
common sense principles, the whole subject is rendered clear and plain, 
and a cure may in most cases be effected. 



40 



CHAPTER XIV. 
DISEASES OF THE URINARY ORGANS. 



SECTION I.— NEPHRITIS. 

By nephritis, from vs$po$, "kidney," and the termination itis, denoting 
inflammation, I mean here inflammation of the kidneys, of either an 
acute or chronic form. 

But as the present chapter is to be devoted to diseases of the urinary 
organs, it is proper that we should take a general glance at the anatomy 
and physiology of these organs, before proceeding to the consideration 
of nephritis, the legitimate subject of the present section. I shall, 
however, only consider the kidneys, ureters, bladder and urethra here, 
leaving the other appendages for consideration in the following chapter, 
in which I shall take up diseases of the genital organs. 

The kidneys, or renal glands, are situated deep in the lumbar region, 
opposite the last dorsal and first lumbar vertebrae. They are composed 
of arteries, veins, nerves, an external cellular covering and the paren- 
chyma. The renal artery is a branch of the aorta, while its veins ter- 
minate in the vena cava, and its nerves are derived from the renal plexus. 

The cellular envelop covers the surface of the kidney, penetrating into 
its fissure, while the parenchyma of the organ is composed of an ex- 
ternal cortical, and an internal tubular portion. 

The cortical substance is a purely glandular structure, about two lines 
in thickness, of a reddish brown color, and composed of blood-vessels, 
and convolutions of the uriniferous tubuli. It constitutes the surface of 
the kidneys, and dips between the cones, surrounding them nearly to 
their apices. 

The diameter of the tubuli uriniferi in the cortical portion of the 
kidney, is about 4 -^th of an inch, and the origin of each uriniferous 
tubule is coiled, being surrounded or associated with a plexus of capil- 
lary vessels in such a manner as to form small granulations about the 
T Joth of an inch in diameter, which have been called the malpighian 
bodies. 

The tubular portion of the organ is of a pale red color, and is com- 
posed mainly of the converging tubuli uriniferi, which, as we have seen, 
commence in the malpighian bodies, in the cortical portion of the kidney. 

The tubuli uriniferi, as they converge from the cortical portion of the 
organ to pass to the pelvis, are separated only by minute blood-vessels, 
and a small quantity of parenchymatous substance, and constitute from 
twelve to eighteen conical fasciculi, enveloped by the cortical substance 
which dips between them, except at their summit. These cones are in- 
vested by mucous membrane, continuous at their apices with the uri- 
niferous tubuli, and so reflected as to form around each, a cup-like pouch 



NEPHRITIS. 627 

or calyx. These calices communicate with the infundibula, or three 
larger cavities, situated at each extremity, and in the middle of the 
organ, constituting by their union a large membranous sac, the pelvis of 
the kidney. 

The ureter, the excretory duct of the kidney, is a membranous tube 
about eighteen inches in length, and nearly the size of a goose-quill, 
being continuous superiorly with the pelvis of the kidney, the inferior 
extremity entering the base of the bladder obliquely between its mus- 
cular and mucous coats. The calices, infundibuli, and pelvis of the 
kidney, as well as the ureter, are composed of an external fibrous, and 
an internal mucous coat, the latter of which is continuous superiorly 
with that of the tubuli uriniferi, and inferiorly with the mucous mem- 
brane of the bladder. 

The bladder, it will be remembered, is an ovoid viscus, of various 
dimensions, situated behind the pubis, and in front of the rectum, con- 
sisting of a body, fundus, base and neck, and being retained in its place 
by numerous ligaments. It is composed of three coats, an external 
serous, which invests the posterior surface and sides from opposite the 
entrance of the ureters to its summit, from whence it glides to the ante- 
rior wall of the abdomen, a middle, muscular coat, consisting of two 
layers, and an internal mucous coat, continuous with that of the ureters 
and urethra. 

The urethra is a membranous canal, extending from the neck of the 
bladder to the meatus urinarius, being composed of two layers, an in- 
ternal mucous, and an external elastic fibrous coat. The mucous coat 
is continuous with the mucous membrane of the bladder, and along its 
course with the lining membrane of the ducts of Cowper's glands, the 
posterior gland, the vasa deferentia, and vesiculse seminales. 

Now, to understand the functions of the urinary organs, it :s only 
necessary to remember the minute structure of the kidneys, and that 
various useless materials, absorbed along the intestines, as well as pro- 
ducts of waste, arising in the system, are here to be separated from the 
blood, and by the urinary organs, to be removed from the system. 

It is probable that the separation of the water of the urine takes 
place in the malpighian bodies, from the arterial blood of the capillaries 
which they contain, while the secretion of the solid portions of the urine 
takes place, as it appears, from the plexus of veins, which ramify on the 
wails of the uriniferous tubes, and receive the blood from the capillaries 
of the malpighian bodies. 

Now the urine thus separated or secreted in the malpighian bodies, and 
in the cells which cover the uriniferous tubes, from the venous plexus 
which surround them, passes along the tubuli uriniferi, constituting the 
cortical fosciculis to the calices, infundibula, and pelvis of the kidneys, 
and from thence along the ureters to the bladder, which serves as a re- 
servoir, from which the urine is finally discharged from the body at in- 
tervals through the urethra. 

Such then are the urinary organs and their functions. And when we 
remember that the average quantity of urine passed by an adult in 
twenty-four hours, is nearly two and a half pounds, and that in every 
1000 parts of this, from twenty to seventy parts are solid matters, con- 



628 DISEASES OF THE URINARY ORGANS. 

sisting of urea, uric acid, lactic acid, lactate of ammonia, and extractive, 
mucus, sulphate of potash, sulphate of soda, phosphate of soda, bi-phos- 
phate of ammonia, chloride of sodium, muriate of ammonia, phosphate 
of lime and magnesia, and silica, the importance of the urinary system 
can hardly be over-rated. 

Having thus taken a glance at the urinary organs, we are prepared 
to appreciate the symptoms which are developed in the various diseases 
which affect their different parts. And as nej>hritis, or inflammation of 
the kidneys, is the legitimate subject of the present section, we will pro- 
ceed to its consideration, and first of its symptoms. 

Symptoms. — The symptoms of nephritis are just what might be ex- 
pected. A pain commences deep in the lumbar region, attended with 
throbbing, and very soon with tenderness to firm external pressure. 

In acute cases, as the disease passes on, there is nausea and perhaps 
vomiting, and sooner or later chills alternating with flushes of heat, fol- 
lowed by febrile reaction, attended with severe pain, great tenderness, 
distressing nausea, and frequent vomiting, especially on making the least 
motion affecting the inflamed organ. The pain darts down the ureters, 
the testicle of the affected side is retracted, and numbness is experienced 
in the thigh of the affected side. 

The bowels are generally constipated and painful, the urine becomes 
scanty, high colored, and perhaps tinged with blood, the desire to mic- 
turate is frequent and urgent, and in most cases, attended with severe 
pain, and yet the secretion of urine is sometimes almost entirely sup- 
pressed. 

If one kidney only is involved, the patient will generally be found 
with the body bent forwards, and a little to the affected side, in order to 
take off the pressure of the lumbar muscles. If, however, both kidneys 
are inflamed, the patient will generally be found in a sitting posture, 
with the body bent forward, or if in bed, with the body bent in the same 
manner, and generally quite unwilling to move. 

The pulse in nephritis is according to my observation, generally full, 
hard, and slow. Sometimes, however, in the latter stages, it becomes 
small and frequent. The skin is warm, dry, and parched, and has a pe- 
culiar rough feeling, probably in part from the irritation which retained 
urine produces in the capillaries of the skin. If suppuration takes place, 
the pus may be discharged with the urine, or it may escape into the 
colon, or into the abdominal cavity in the latter case, a fatal termination 
will be the result. 

Such I believe are the ordinary symptoms of acute nephritis. But the 
disease may pass on and become chronic, or it may be so from the first. 
In either case, there is little or no fever, the pain is dull, and confined 
to the inflamed organ, and the remaining symptoms, though similar in 
kind, are of less intensity, and the disease may continue for a long time 
if neglected, the urine becoming alkaline, and the disease being finally 
attended with night-sweats, hectic, emaciation, &c. 

When nephritis is about terminating favorably, by resolution, the 
fever and pain subside — the skin becomes moist, the urine free, and the 
nausea and vomiting cease. If, however, suppuration takes place, rigors 
supervene — the pulse becomes weak, night sweats occur, and the urine 
first becomes turbid, and then clearly purulent. 



NEPHRITIS. 629 

Such, then, are the ordinary symptoms of nephritis, as it occurs in 
the acute and chronic form. 

Diagnosis. — Nephritis is liable to be confounded with nephralgia, in- 
flammation of the psoas muscle, and lumbago ; from all of which it may 
be distinguished, however, by attention to the following differences. 

From nephralgia, it differs in being attended with fever, while in the 
nervous affection the pain is generally more severe, and of a spasmodic 
character. 

From inflammation of the psoas muscle, it may be distinguished by 
the relief which is produced by bending the body forwards, while in that 
disease the pain is increased by that position ; and, besides, in nephritis 
there is the fever, changed appearance of the urine, &c, which do not 
necessarily attend the psoas disease. 

From lumbago, nephritis differs in the deep and throbbing character 
of the pain, as well as in the derangement in the urinary secretion, 
while in lumbago the pain is more superficial, and the urinary secretion 
may remain quite natural. 

Causes. — The causes of nephritis are various, among which cold, sud- 
denly applied, is probably the most frequent, especially as the kidneys 
sympathize strongly with the skin. Nephritis may also arise from stimu- 
lating diuretics, as well as from diseases of other portions of the urinary 
organs. 

Renal calculi sometimes produce this disease, by the mechanical irri- 
tation which they produce, a remarkable case of which fell under my 
observation in this village, about two years since. 

Metastasis of gout and rheumatism may produce nephritis of the 
most violent character, a severe case of which fell under my care a few 
years since, in a gentleman about sixty years of age. 

Morbid Appearances. — In cases in which death has taken place early, 
the kidney is found enlarged and congested, and its cortical portion 
of a reddish-brown color. The tissue of the gland is unusually softened, 
and the mucous membrane of the pelvis is generally thickened and red- 
dened. 

If death has taken place at a later stage of the disease, pus may be 
found in the glandular structure, either disseminated or in small cavities. 
Or the pelvis of the kidney may be found filled with pus. 

In chronic cases the kidney may be found contracted, and perhaps 
indurated, its surface presenting an irregular rough appearance. 

In a case, however, that I examined a few years since of long stand- 
ing, which had been attended for years, with purulent discharge with 
the urine ; the glands involved was enormously enlarged, its internal 
structure destroyed, and besides pus and a small quantity of blood, it con- 
tained a calculi of large size, which had probably produced the disease. 

Treatment. — The treatment, if applied early, or during the forming 
stage of renal inflammation, may be effectual in at once arresting the 
disease. At such a stage, the abstraction of a few ounces of blood from 
over the kidneys, by cups ; a mild cathartic, and the warm foot-bath, 
with low diet, and mucilaginous drinks, may be sufficient to arrest the 
disease. 

But if the disease is acute, or has been neglected, or is of an aggra- 



630 DISEASES OP THE URINARY ORGANS. 

vated character ; general bleeding may be indicated. After the general 
bleeding, in cases in which it is indicated, and at first when not, from 
four to six ounces of blood should be taken by cups, from over the region 
of the kidneys, on each side of the spine, and this may be repeated in 
the course of twenty-four hours, if the pain, tenderness, and vomiting 
continue unabated. 

After the cupping, hops wet in warm vinegar, should be laid over the 
lumbar region, and continued during the continuance of the inflamma- 
tion, for the purpose of promoting perspiration, and also for the anodyne 
influence, which the hops produce. 

Immediately after the bleeding, if indicated, and cupping, a cathartic 
of calomel should be administered, in castor oil, and its operation secured, 
if necessary, by mucilaginous injections, as much uneasiness is usually 
produced by the operation of a cathartic. After the first cathartic, the 
bowels should be kept moderately loose, by injections of flax-seed tea, 
with a little castor oil, rather than by administering cathartics. 

After the operation of the cathartic, in violent cases, two grains of 
calomel with four grains of Dover's powder, may be given every four 
hours, and continued till a slight ptyalism is produced, if the inflamma- 
tion is not sooner subdued; when the calomel should be omitted, and the 
Dover's powder continued, every six hours, till the fever subsides. 

After the fever subsides, and in all cases in which there is no fever ; 
fifteen drops of the fluid extract of hyoscyamus, may be given as an 
anodyne, every six hours, with thirty drops of the sweet spirit of nitre, 
if this is from no cause contra-indicated. 

Mucilages should be freely allowed, during the whole course of the 
disease. And in rheumatic or gouty cases, nitre, colchicum, or iodide of 
potassium should be given, in addition to what I have already suggested. 
Crust coffee should be allowed at first, with a little milk, and later, arrow- 
root, tapioca, rice, and finally toast. In very protracted chronic cases, 
a drachm of the fluid extract of uva ursi, or two ounces of the infusion, 
may be given, four times per day, and if a tonic is required, ten drops 
of the tincture of chloride of iron, may be given after each meal, as long 
as may be required. 

SECTION II.— ALBUMINURIA. 

By albuminuria, I mean here that variety of organic renal disease in 
which, in addition to a general depraved condition of the system, there 
is the presence of albumen in the urine, and in many cases dropsy and 
various other complications. 

The constitutional depravity, I believe, is nearly the same in kind, 
only differing in degree, in all cases of this disease ; while the renal 
degeneration differs not only in degree, but in kind, the kidneys being 
in some cases inflamed, in others tuberculous, in others granular, in 
others atrophied, and in others still, having undergone the fatty, waxy, 
or fibroid degeneration. In fact, I have seen cases in which several of 
these conditions existed at the same time, one portion of the kidneys 
being granular, another tuberculous, and another portion still being 
atrophied, or otherwise changed. 



ALBUMINURIA. 631 

I believe that in every form of this disease there is the presence of 
more or less albumen in the urine, which fact is a sufficient reason for 
calling it albuminuria, a term which the most invariable symptoms sug- 
gests, and which must suffice for want of a better or more indicative 
term. 

Symptoms. — In some cases of this disease the renal affection appears 
to be developed first, the constitutional depravity following, in part, as 
a consequence. 

I believe, however, from careful observation, that the constitutional 
depravity generally precedes the organic renal affection, or that a strong 
constitutional predisposition to this form of disease exists, at least. In 
such cases, however, the renal degeneration, when it progresses suffi- 
ciently to allow of a free discharge of albumen, at the same time causing 
a retention in the blood of effete matters, greatly aggravates the general 
depravity, and hastens the disease on to a fatal termination. 

When the renal disease commences, whether primary or secondary, 
there is generally a chill, more or less severe, attended with pain in the 
head, back, and lower extremities, followed by febrile reaction, with a 
hot and dry skin, a full, and perhaps frequent pulse, and in many 
cases with numbness of the lower limbs and retractions of one or both 
testicles. 

In the more chronic form of the disease, however, the renal affection 
may be developed without a sensible chill, or any very marked constitu- 
tional disturbance. In such cases, however, as well as in those in which 
the febrile symptoms are marked, the urine becomes gradually scanty, 
and is passed with difficulty, the rapidity of this change being generally 
in proportion to the activity of the disease. As the renal disease pro- 
gresses, a dull pain is experienced in the region of the kidneys ; and if 
the patient has had scrofulous sores, or glandular swellings about the 
neck, they are apt to disappear ; and if there has been a troublesome 
cough, it may subside. 

By degrees the urine becomes scanty, of a low specific gravity, and 
highly albuminous ; the complexion becomes anaemic and sallow, emacia- 
tion progresses, the muscles become weak, the appetite is defective, 
digestion, sanguification, and nutrition become impaired, and constipa- 
tion attends, alternating with diarrhoea, &c. ; and finally, along with 
drowsiness, languor, and stupidity of the most intolerable character, 
there is apt to be the supervention of oedema and anasarca, with perhaps 
hydrocephalus, hydrothorax, hydropericardium, &c. 

After this train of symptoms has continued for an indefinite time, 
varying from a few weeks to several months, or even years, the patient 
becomes emaciated, stupid, and generally dropsical, and is relieved by 
death from one of the most intolerable conditions which it has been my 
misfortune to witness. In some cases, however, the patient dies in a 
comparatively early stage of the disease, in which case many of the un- 
pleasant symptoms enumerated above are not experienced, or what is 
better still, if the constitutional depravity is not too great, and the case 
is properly treated in season, a recovery may sometimes take place, 
but I believe that such an event is only an exception to a rule. 

Such, I believe, are the ordinary symptoms of what I have called 






632 DISEASES OP THE URINARY ORGANS. 

albuminuria, but which has sometimes been known as granular, Bright' s 
disease, &c. 

Anatomical Characters. — On post-mortem examination the kidneys 
present a variety of appearances, being either enlarged or contracted 
among the most frequent of which are signs of congestion and inflam- 
mation, especially of the cortical portion, small granulations and tuber- 
cles in various stages of advancement, an atrophied condition in which 
the lining of the secretory tubules is lost, and the organ greatly 
shrunken, fatty degeneration in which there is an excess of oil in the 
epithelial cells of the tubules, the waxy degeneration in which with 
great enlargement there is a deposit of waxy-looking matter in the 
tubules, and elsewhere, and finally a filroid degeneration, analogous to 
cirrhasis in the liver and lungs, an interesting case of which fell under 
my observation a few years since in a patient about sixty years of age. 

Diagnosis. — Cases of albuminuria may generally be distinguished by 
the albuminous urine, the cachetic or depraved condition of the system, 
the scantiness and low specific gravity of the urine, the dropsical ten- 
dency, and finally by the dull pain in the back, and at last the drowsi- 
ness, stupidity &c. which supervene. 

To distinguish the different varieties of this disease, it is well to 
remember that in inflammatory cases the urine is very scanty, often 
bloody, and contains a large amount of albumen. In the granular and 
tuberculous cases, the urine is still highly charged with albumen, but I 
believe it is generally a little more free. In the atrophic cases the urine 
may be quite free, is of low specific gravity, but moderately albuminous, 
and the dropsical tendency is not very strong. In cases of fatty degen- 
eration, the system is cachetic from the first, dropsy generally attends, 
and the urine is always scanty, of low specific gravity, and albuminous. 
In cases of waxy degeneration, the tendency to dropsy is slight, the 
disease is chronic, and the urine is highly albuminous, and may contain 
waxy casts. Finally, in the filroid degeneration, there is the same 
train of symptoms as in the waxy, except that the urine may contain 
fibrinous instead of waxy casts. 

In many patients, however, several of these conditions exist, even in 
the same kidney, in which case it is impossible to do more than to form 
a general diagnosis till an examination is made post mortem. 

Causes. — The predisposition to albuminuria doubtless consists in an 
inherited or acquired scrofulous or otherwise depraved condition of the 
system, while the exciting causes are as numerous as can well be ima- 
gined, embracing almost every variety of imprudence to which the 
human family are addicted. It is probable, however, that the most fre- 
quent exciting causes of this disease are nephritis, scarlatina, sexual 
excesses, a syphilitic taint, the use of tobacco, filth, improper food and 
clothing, and protracted drunkenness. 

Nature. — Now, if we bear in mind the depraved condition of the sys- 
tem which attends, and probably generally precedes the organic renal 
affection ; and the local and constitutional derangements which supervene 
from a derangement or suspension of the renal function, together with 
the causes which operate to produce the disease, its nature becomes 
comparatively plain. 



ALBUMINURIA. 633 

For in cases in which the renal affection is secondary, the constitu- 
tional depravity favors the renal degeneration, whether it be granular, 
tuberculous, atrophic, or of the fatty waxy or fibroid character. And no 
sooner has one or several of these organic conditions become established, 
with or without the supervention of renal inflammation, than this con- 
dition, by draining off the albumen from the blood, and causing to be 
retained in the blood various effete matters, not only augments the 
general depravity of the system, but also leads on to dropsical and other 
complications which follow towards the fatal termination of this disease. 

That the general condition of the system may be very similar in all 
cases of this disease, is rendered probable by the fact that several varie- 
ties of the renal degeneration enumerated above, sometimes exist in the 
same case, an interesting specimen of which fell under my observation 
in this village a few years since. It is probable then that the kind of 
renal degeneration in this disease, may depend very much upon acci- 
dental causes, operating directly upon the kidneys, modified of course 
by the habits of the patient, and perhaps by shades of variation in the 
general depravity of the system, which invariably attends in this disease. 

Prognosis. — In all cases of this disease, in which the general depra- 
vity of the system is considerable, and the organic renal affection, of 
whatever form it may be, is considerably advanced, the prognosis is de- 
cidedly unfavorable, as a fatal termination will generally be the result. 
In cases, however, in which the general derangement is slight, if the 
quantity of albumen detected in the urine by heat or nitric acid is 
moderate, and the renal disease is in its incipient stage, and consists 
merely of congestion, inflammation, or perhaps fatty degeneration, a 
favorable termination of the case may be anticipated, if the cause can be 
removed, and the patient be subjected to proper treatment. 

Treatment. — The indications in the treatment of this disease are to 
correct the habits and general condition of the patient, to subdue fever 
and renal inflammation if they arise, and finally to remove dropsical 
accumulations when they occur, as they are very liable to in this disease. 

The patient should be made to abandon all impure, or intemperate 
habits, and should be directed to take proper food, with strict regula- 
rity, should keep the skin clean, and wear clean and suitable clothing, 
should sleep in dry apartments, and if possible take moderate exercise 
in the open air, and finally should be prudent and temperate in all things. 

If the bowels are confined, a teaspoonful of cream of tartar may be 
given morning and evening, and if the patient is decidedly anaemic, ten 
drops of the tincture of chloride of iron may be given three times per 
day, after each meal, and continued for a reasonable time. 

Should fever occur, as it is apt to in acute cases, half an ounce of the 
bitartrate of potassa may be given, if necessary, morning and evening, 
the dose being gradually diminished to a teaspoonful, as the fever sub- 
sides. And during the febrile excitement, five grains of Dover's powder 
may be given every six hours, to quiet the patient and promote perspi- 
ration. 

If pain, with symptoms of renal inflammation occurs, whether at the 
commencement, or at any subsequent stage of the disease, cups should 
be applied on each side of the spine in the lumbar region, and a few 



634 DISEASES OF THE URINARY ORGANS. 

ounces of blood taken. This may be repeated, if necessary, and when 
no longer admissible, dry cupping may be resorted to, or pustulation 
may be produced by tartar emetic, either in the form of an ointment, or 
else sprinkled on a plaster to be worn over the part, of either conium, 
belladonna, or stramonium. 

Finally, if the disease passes on, and there is evidence of the fatty, 
or other forms of renal degeneration, with dropsical accumulations, 
drowsiness, &c, in addition to what I have already suggested, five 
grains of the iodide of potassium should be given three times per day, 
with ten drops of the fluid extract, or half an ounce of the infusion of 
digitalis, and this should be continued till the dropsical and other urgent 
symptoms are relieved, or a fatal termination occurs. The digitalis may 
not be tolerated, however, for a great length of time, but the iodide may 
be given, in such cases, as long as required. 

SECTION III.— NEPHKALGIA. 

By nephralgia from v£tp°s, "a kidney," and ayXo$, "pain," I mean 
here neuralgia of the kidney, unattended with inflammation or febrile 
excitement. 

In order to appreciate the symptoms which are developed in this af- 
fection, it is necessary to remember the situation of the kidneys, op- 
posite the last dorsal and first lumbar vertebrae, and also their intimate 
sympathetic relations with the digestive organs, and other portions of 
the system. 

Symptoms. — Nephralgia commences often very suddenly in one or 
both kidneys, the pain being at first confined to the region of the gland, 
but extending in most cases along the ureters, as well as into the back, 
hip, and thighs. The pain is of an acute, darting, or lancinating char- 
acter, and may be continuous, but it is oftener of an intermittent, or re- 
mittent character, at least it has been so in cases that have fallen under 
my observation. 

During the severe paroxysms of pain, the testicles are apt to be re- 
tracted, the stomach strongly symphathizes, flatulence and colic attend, 
and the urine may be either scanty or very copious, and it in some cases 
contains a sandy deposit of an acid or alkaline character. 

Diagnosis. — Nephralgia may be distinguished from nephritis, by the 
suddenness and violence of the attack, the spasmodic and intermittent 
character of the pain, the absence of tenderness and febrile excitement, 
and finally by the sudden suspension of the pain, the patient appearing 
very soon quite well. 

Causes. — Various causes may operate to produce nephralgia, such as 
produce neuralgia of other parts. I believe, however, that spinal irri- 
tation, the presence of sandy deposits in the urine, and in some cases 
the passage of calculi along the ureters, with perhaps a rheumatic or 
gouty condition, most frequently act as causes of this disease. 

Treatment. — When an attack of nephralgia occurs, the cause direct 
and remote, should be ascertained and removed if possible. To relieve the 
pain, which is often intolerable, cups should be applied on each side of 
the spine, in the lumbar region. The cupping may be repeated if neces- 



ACUTE CYSTITIS. 635 

sary, and a fomentation of hops wet in "warm vinegar kept applied, over 
the lower portion of the abdomen, and across the lumbar region. 

Internally, to quiet pain, fifteen or twenty drops of the fluid extract 
of hyoscyamus should be given, and repeated if necessary, every four 
or six hours. Mucilage of gum arabic should be freely allowed, and if 
the bowels are constipated, a cathartic of calomel or podophyllin should 
be administered in castor oil, and in rheumatic cases, iodide of potassium 
or colchicum may be required. 

SECTION IV.— ACUTE CYSTITIS. 

By acute cystitis, is here meant acute inflammation of the bladder, 
whether one or more of its coats be involved in the inflammation. 

The bladder, it will be remembered, is situated in the anterior part 
of the cavity of the pelvis, back of the pubis, in front of the rectum in 
the male, and of the uterus in the female, and is of various dimensions. 
It is composed of three coats, an internal mucous, a middle muscular, 
and an external serous, derived from the peritoneum, which covers the 
posterior lateral and superior regions of the bladder, adhering to that 
portion of its muscular coat. 

The arteries supplying the bladder, come from the hypogastric, and 
its veins go to the hypogastric veins, and it is supplied with nerves from 
the sciatic and hypogastric plexuses. 

The bladder thus situated and constituted, is liable to become inflamed, 
and when it does, the symptoms which are developed, are such as might 
be expected, from its combination of serous, muscular, and mucous 
tissues. 

Symptoms. — The first symptoms of acute cystitis, is generally pain 
in the region of the bladder, its character depending upon the seat of 
the inflammation. 

If the mucous membrane is the principal seat of the inflammation, 
the pain is of a burning character ; if the muscular coat, it is of a throb- 
bing aching character ; but if it is confined mainly to the peritoneal 
coat, the pain is of a sharp lancinating character. If, however, as 
generally happens, the mucous, muscular, and peritoneal coats all be- 
come involved, there is a combination of the different varieties of pain. 

In some cases before, and in others, after the commencement of the 
pain, there is a chill, followed by febrile excitement ; this being severe 
or slight, according to the intensity of the disease. There is frequent 
and distressing micturition, and the pain generally extends to the testi- 
cles and upper part of the thighs, and is attended with a sense of con- 
striction in the hypogastric region. 

The pain is increased, by pressure made above the pubis, and more 
or less tenderness also exists in the perineum. The pulse is full, hard, 
and frequent ; the skin hot and dry ; the thirst urgent, and the patient 
more or less restless and dejected. 

The bowels are constipated, and if the posterior portion of the blad- 
der is involved, there is apt to be troublesome tenesmus. If that portion 
is inflamed which admits the ureters, these tubes may become inflamed, 
obstructing the passage of the urine to the bladder, and leading to se- 



636 DISEASES OP THE URINARY ORGANS. 

vere pain and tenderness in the hypogastric Region. When the neck of 
the bladder becomes seriously involved, there is sometimes total reten- 
tion of urine, or the patient is tormented with constant and distressing 
sensations of strangury. 

The inflammation in acute cystitis, terminates either in resolution, 
suppuration, gangrene, or induration, and thickening of the coats of the 
bladder. 

When the inflammation is terminating by resolution, the pain subsides, 
the fever abates, there is a general and uniform diaphorisis, and the 
urine becomes copious, and is passed with little or no pain. If, however, 
there is an abatement of the fever, and subsidence of the pain, accom- 
panied with chills or rigors, and an appearance of white or yellowish 
matter in the urine, suppuration has taken place. But if gangrene oc- 
curs, with the cessation of pain, there is a profuse clammy perspiration, 
the extremities become cold, the strength fails, the countenance becomes 
cadaverous, the mind becomes confused, and with a small, weak, and 
frequent pulse, with perhaps hiccough, the disease passes on to a fatal 
termination. 

Dissection in fatal cases, discovers an injected appearance, with irre- 
gular patches, perhaps softened or partially disorganized. In some 
cases the signs of inflammation, are confined mainly to the mucous coat, 
in others, to the muscular, and in others still, to the peritoneal; but 
generally in cases that have been acute, all the coats show signs of having 
been involved. 

Ulcers are frequently found, involving the mucous and muscular coat, 
and pus, either infiltrated, or occupying small cavities in the walls of 
the bladder, is a very common morbid appearance in this disease. The 
cellular tissue is also occasionally infiltrated with serum, and lymph or 
pus ; and portions of the bladder, are sometimes found in a gangrenous 
state. 

Causes. — A great variety of causes, may operate to produce acute 
cystitis ; among the most frequent of which are blows, stone in the blad- 
der, severe labors, riding on horseback, irritating injections, cantharides, 
oil of turpentine, &c, exposure to cold, the translation of gout or rheuma- 
tism, extension of inflammation from contiguous structures, and finally, the 
the retrocession of cutaneous eruptions. 

Treatment. — In the treatment of acute cystitis, general bleeding is in 
many cases indicated, and should not be neglected. Cups too, should be 
applied over the sacrum, perinaeum, and hypogastrium, and more or less 
blood taken, or leeches may be applied, if at hand. After the cupping 
or leeching, a poultice of hops, moistened in warm vinegar, should be 
applied to the perinseum and hypogastrium, and continued, duriug the 
continuance of the inflammation. 

A cathartic of calomel should be administered in castor oil, and its 
operation promoted, if necessary, by an injection of flaxseed tea, with 
half an ounce of castor oil. After the first cathartic, the bowels should 
be kept regulated by small doses of the sulphate of magnesia ; and in 
acute cases, in which the inflammation is not arrested by the bleeding, 
cupping, cathartic, &c, two grains of calomel, with four grains of 
Dover's powder, may be given every four hours, and continued till an 



CHRONIC CYSTITIS. 637 

impression is produced upon the inflammation, or slight ptyalism is 
produced. At this stage the calomel should be omitted, and the Dover's 
powder continued, with three grains of James's powder, while a diapho- 
retic is required. 

After the inflammation and febrile excitement have passed by, if an 
anodyne is required, fifteen drops of the fluid extract of hyoscyamus 
may be given every six hours, with mucilages for drink, only the 
plainest kind of unstimulating food being allowed. Warm pediluvia 
should be used during the whole course of the disease ; and should the 
case be of a rheumatic character, colchicum, or iodide of potassium, may 
may be required to complete a cure. 

SECTION V.— CHRONIC CYSTITIS. 

By chronic cystitis, I mean here a slow or protracted inflammation of 
the mucous membrane of the bladder, the muscular and peritoneal coats 
being but slightly, if at all, involved. 

Chronis cystitis is not a very unfrequent affection, sometimes coming 
on as an original disease, and in other cases following acute cystitis, 
especially such cases as are confined mainly to the mucous membrane, 

Symptoms. — Chronic cystitis may come on very slowly, or the onset 
may be more abrupt, in either case the symptoms being in many respects 
similar to those of acute cystitis, but differing in degree. The patient 
experiences pain, with a sense of heat in the region of the bladder, and 
a feeling of weight and tenderness in the perinseum. 

The desire to urinate is often frequent, and the effort attended with 
distress, and a spasmodic action of the bladder and urethra. The urine 
is loaded with tenacious mucous early in this disease, assuming, as the 
inflammation progresses, a whitish, yellowish, and perhaps bloody 
appearance, the quantity passed, in some cases, being very considerable. 

As the disease progresses, a slow irritative fever may supervene, the 
pains increase and extend to the neighboring parts ; pus, instead of 
mucus, is discharged with the urine ; the strength fails, emaciation 
progresses, and, unless the disease be arrested, it now passes on rapidly 
to a fatal termination. 

Dissection in fatal cases discovers a softened, ulcerated, and exten- 
sively disorganized condition of the mucous membrane, and the muscu- 
lar coat is often contracted, thickened, and of a firm consistence, as 
well as the ureters enlarged, and ulcerative perforations are sometimes 
formed, extending even into the structure of neighboring organs. 

Causes. — Among the numerous causes which may produce chronic 
cystitis, I believe that the most frequent are stone in the bladder, irri- 
tating injections, exposure to cold and dampness, excessive venereal 
indulgence, onanism, the use of alcoholic drinks, sedentary habits, and 
finally masturbation, the use of tobacco, &c. 

Prognosis. — In most cases of chronic cystitis, if the cause can be 
removed, and the case be subjected to proper treatment in season, a 
favorable termination may be anticipated. In cases, however, in which 
the system is depraved and debilitated, and the cause which is operating 
does not admit of removal, the condition may perhaps be palliated, but 
a fatal termination will be the final result. 



638 DISEASES OF THE URINARY ORGANS. 

Treatment. — The habits of the patient should be corrected at once, 
and only plain, digestible food allowed to be taken with strict regularity. 
The patient should wear proper clothing, and, if possible, take gentle 
exercise in the open air. 

Cups or leeches should be applied at first to the sacral and. hypo- 
gastric regions, and later, if necessary, pustulation may be produced at 
either of these points, or on the perineum, by tartar emetic ointment. 
Mucilages should be allowed, and the bowels should be kept regular by 
moderate doses of magnesia or castor oil, if required. As a tonic, the 
tincture of chloride of iron, in ten drop doses, three times per day, will 
do best ; and to act especially upon the diseased membrane, a drachm 
of the fluid extract, or an ounce of the infusion of buchu, may be given 
four times per day, till a cure is effected. 

SECTION VI.— DIABETES MELLITUS. 

By diabetes mellitus, I mean here that peculiar disease in which there 
is a copious secretion of saccharine urine, indigestion, constipation, a 
dry skin, thirst, a voracious appetite, and progressive emaciation. 

This form of disease is apt to come on slowly, and in most cases that 
have fallen under my observation, there has been a weak or watery state 
of the blood, an irritable condition of the nervous system, and evidence 
of more or less congestion of the lower portion of the spinal cord. 

The quantity of water discharged in this disease is often very great, 
amounting, in some cases, to three or four gallons in twenty-four hours. 
This, however, constitutes the almost entire liquid evacuation in such 
cases, as there is little or no exhalation from the skin, and the alvine 
evacuations are almost entirely dry. 

The urine has a pale straw color, its smell resembles that of milk, and 
it has a sweetish taste, from the sugar which it contains, which appears 
to take the place of urea in healthy urine. 

Symptoms. — Diabetes mellitus first becomes apparent, by the frequent 
calls to urinate, and more or less indigestion, attended with variable 
appetite, together with acid eructations, occasional nausea, vomiting, &c. 
As the disease progresses, these symptoms become greatly aggravated, 
the thirst becomes urgent, the appetite craving, the skin dry ; there is 
an uneasiness in the stomach after eating, the mouth becomes dry, the 
tongue foul, and sometimes reddish, emaciation proceeds, and, along with 
great wasting of flesh, there is an increasing disinclination to physical 
or mental exertion. Along with pain, there is great weakness in the 
loins ; the bowels become obstinately constipated, the orifice of the 
urethra becomes irritable, there is loss of virility, the extremities be- 
come cold, and, along with vertigo, there is headache, and more or less 
difficulty of breathing. 

As the disease draws on towards a fatal termination, the urine becomes 
scanty, the gums become spongy, the breath fetid, the voice rough and 
unnatural, emaciation proceeds rapidly, and the patient finally sinks into 
a state of somnolency or stupor, from which it is often impossible to 
keep him roused for a moment. 

The pulse is but little, if at all, accelerated during the early stage of 



DIABETES MELLITUS. 639 

the disease, being in some cases less frequent than in health ; but, during 
the latter stages, when the emaciation and exhaustion are very great, the 
pulse becomes weak and quick, or otherwise irregular. The urine is of 
a high specific gravity, from the saccharine matter which it contains, 
amounting, in some cases, to two or three ounces to the pint, the amount 
of urea being diminished as the sugar is increased. 

The duration of this disease is exceedingly various, in some cases con- 
tinuing only a few days or weeks, while in others it continues for months, 
or even years, before a fatal termination takes place. In some cases, 
the diabetic symptoms recur in a periodical manner, the exacerbations 
being gradually more frequent, till all the symptoms become continuous, 
the final termination of the disease being very generally comatose or 
apoplectic. 

Diagnosis. — Diabetes mellitus may be distinguished from diabetes 
insipidus, by the greater severity of the symptoms, and by the presence 
of sugar in the urine. This saccharine matter may be detected by the 
taste, or by adding yeast to the urine, when, if sugar be present, effer- 
vescence will take place, if the mixture be exposed to a temperature of 
70° or 80°, the liquor assuming a vinous odor. 

Anatomical Characters. — The morbid appearances presented in fatal 
cases of this disease are of the kidneys, stomach, intestines, mesenteric 
glands, lungs, and of the nervous centres. 

The kidneys are generally found in a relaxed state, and their blood- 
vessels enlarged, as if having been congested while in a partially para- 
lyzed condition. Both the cortical and tubular portions of the kidneys 
often show signs of having been thus congested ; rendering the gland 
in some cases much larger than in a healthy state. 

The alimentary mucous membrane in most cases shows signs of recent 
inflammation ; and the mesenteric glands are either enlarged, or else 
present a softish and relaxed appearance. The lungs, brain, and spinal 
cord often present a relaxed or congested appearance ; and the skin 
is rough ; the perspiratory tube appearing very much contracted, or en- 
tirely closed. 

Causes. — There is probably a hereditary predisposition to this dis- 
ease, in some individuals, consisting perhaps in a relaxed condition of 
the tissues of the body, and an irritable state of the nervous system. 
And I suspect that a similar predisposition may be acquired by various 
imprudences; such as masturbation, venereal excesses, the use of to- 
bacco, alcoholic liquors, filthy habits, improper food, clothing, &c. 

Among the numerous exciting causes of this disease, are exposure to 
cold and dampness, irregular eating, protracted grief, anger, injuries of 
the brain or spinal cord, unwholesome food, deficient clothing, bad air, 
and various others of a kindred character. 

Nature. — Now the local points to which the symptoms naturally call 
our attention, are the stomach, skin, liver, kidneys, and nervous centres ; 
and the causes which operate, as well as the post-mortem appearances, 
point to deranged digestion, sanguification, and secretion ; while others 
in turn look back to a hereditary or acquired weakness, or depraved 
state of the blood, and irritable condition of the nervous system. 

Now, it appears to me, that with this inherited or acquired deranged 



640 DISEASES OF THE URINARY ORGANS. 

condition of the blood and nervous system, together with the general 
relaxed condition of all the tissues of the body, which prevails in such 
cases, a tolerable satisfactory explanation may be had of the nature of 
this disease. 

For, in this state, it is only necessary that any one of the exciting 
causes of this disease, as improper food, irregular bating, &c, should 
be brought to bear ; in order to impair digestion, derange sanguification 
and secretion, and finally to lead on to a development of all the symp- 
toms which attend this form of disease. 

It is probable, also, that a weak or irritable condition of the brain 
and spinal cord favors an interruption of the digestive function, as well 
as an augmentation of the renal secretion, which are the two most 
prominent features of this disease, except the saccharine urine. The 
presence of sugar in the blood, instead of urea, and its separation by 
the kidneys, I believe is owing to a deficiency of nitrogen. 

For it will be remembered that the quantity of hydrogen in a given 
weight of sugar and urea, is precisely the same ; but the urea contains 
a large proportion of nitrogen, while sugar contains none. Now, from 
the defect of nitrogen, in the process of sanguification, urea cannot be 
formed, but sugar is formed instead, with its carbon and oxygen ; and 
hence its separation by the kidneys with the urine, instead of urea, 
which appears in the renal secretion in a healthy state. 

In relation to this defect of nitrogen, I suspect it may arise in part 
from a too exclusive vegetable diet, and also in part from defective 
power in the digestive organs, in consequence of which a due amount of 
pepsin is not formed, the office of which, in a healthy stomach, may be 
to nitroginize the food. 

Now, the saccharine matter in the blood, together with the deranged 
condition of the nervous system, causes an excessive secretion of urine, 
which draught upon the system, leaves the skin dry, the bowels costive, 
the thirst urgent, and the appetite voracious. Digestion and sanguifi- 
cation gradually become more imperfect, emaciation progresses, and 
finally when the powers of the system are exhausted, the renal function 
is gradually suspended, and the retained urinous matter acting upon 
the brain, produces drowsiness, coma, and finally death. 

Prognosis. — The prognosis in this disease is generally decidedly un- 
favorable, and yet with proper treatment in season many cases may be 
palliated, and some even permanently cured. 

The favorable symptoms are a diminished secretion of urine, and a 
reappearance of uric acid instead of sugar in the urine, together with a 
palliation of all the symptoms which generally attend or follow this 
change. The unfavorable indications are the continuation and increase 
of all the symptoms, with the evidence, which sometimes appears, of or- 
ganic renal disease, and the final suppression of urine, with the cerebral 
symptoms which follow, all of which point to a fatal termination. 

Treatment. — In all cases of diabetes mellitus the causes should be 
sought out and removed, if possible, and the habits of the patient should 
be corrected. This being accomplished, the exact deviation from the 
standard of health should be taken, and the indications thus arrived at, 
should be fulfilled by the most convenient, safe, and reliable remedies. 



DIABETES INSIPIDUS. 641 

The patient should abandon any imprudent or improper habits, should 
keep the skin clean, should wear clean and warm clothing, and to fur- 
nish a due amount of nitrogen to the system, and at the same time to 
avoid the sugar-making materials, the patient should be placed on an 
almost exclusively animal diet, to be taken with strict regularity. Only 
a reasonable amount of drink should be allowed, and this should consist 
of water, milk, tea, or coffee. And as the appetite is apt to be vora- 
cious, the quantity of food should be restricted, and this should be 
thoroughly masticated and taken slowly. 

To correct the acidity and constipation which attend in this disease, 
magnesia may be given, morning and evening, in quantity sufficient to 
keep the bowels moderately loose, and this should be continued while 
the constipation and acidity lasts, or during the continuance of the dis- 
ease. 

As a tonic for the blood, the sulphate, carbonate, or ammoniated 
citrate of iron should be given, in two or three grain doses, after each 
meal, and continued for a long time. And as a tonic for the nervous 
system, and to improve digestion, ^h of a grain of the muriate of 
strychnia may be given in solution, before each meal, and continued for 
a time. 

In cases, however, in which there is local irritation in the brain, or 
along the spinal cord, the strychnia should not be given. To improve 
digestion in such cases, thirty drops of the fluid extract, or half an 
ounce of the infusion of columbo may be given instead, before each meal, 
and continued for a time. 

In bad cases, to diminish the renal secretion, and to favor diaphoresis, 
five grains of Dover's powder may be given four times per day. In 
milder or more chronic cases, however, half a grain of ipecac may be 
substituted, and continued as long as may be required. In cases in 
which there is irritation at some point along the spine, in addition to 
the treatment I have already suggested, dry cups may occasionally be 
applied. 

SECTION VII.— DIABETES INSIPIDUS. 

By diabetes insipidus, I mean here that variety of disease in which 
there is an excessive secretion of urine, without saccharine matter ; the 
urine either appearing natural, being constituted of its ordinary consti- 
tuents, or else containing an excess of urea, or more or less chyle or 
albumen. 

1 believe that in a large majority of the cases of this disease there 
is an excess of urea, while the presence of the other ingredients men- 
tioned are only occasional, depending upon accidental circumstances. 

Symptoms. — After an indefinite period of general derangement of 
the system, during which the appetite is variable, the bowels occa- 
sionally constipated, and the cutaneous functions more or less deranged, 
the patient gradually becomes annoyed by frequent calls to urinate, 
and the quantity of urine passed becomes at times very great. 

In some cases the copious flow of urine is only occasional, following 
an undue amount of physical or mental excitement. In such cases, 
41 



642 DISEASES OF THE URINARY ORGANS. 

and I believe in most cases of this disease, more or less pain is expe- 
rienced in the loins, and not unfrequently there is tenderness along the 
dorsal or lumbar portion of the spine. 

In cases in which the excess of urea is very considerable, there is 
often a disposition to pass water very frequently, both day and night ; 
and especially is this the case if the weather is cold, or if the patient is 
laboring under undue mental excitement. 

In severe cases of diabetes insipidus the thirst becomes urgent, the 
appetite craving, the skin dry, and the bowels obstinately constipated ; 
and, if the disease continues, emaciation follows, with perhaps the chy- 
lous or albuminous urine, but never the saccharine. The disease seldom 
terminates fatally ; but is apt to be associated with a weak state of the 
blood, and a deranged and irritable condition of the nervous system, 
so that the patient becomes exceedingly uncomfortable, and is ren- 
dered especially liable to be cut down by some sudden attack of acute 
disease. 

Diagnosis. — Diabetes insipidus may be distinguished from diabetes 
mellitus by the less severity of all the symptoms, and by the absence of 
sugar, and presence of urea in the urine ; while the reverse obtains in 
the other variety of the disease. Besides, in this variety, animal food 
always aggravates the disease ; while in the other, animal food palliates, 
and vegetable food aggravates all the symptoms ; a discovery that 
many patients make even before they resort to medical advice. 

Causes. — Any train of influences that weakens the blood, renders the 
nervous system irritable, and impairs digestion, may operate as predis- 
posing or exciting causes of this disease. Among these causes are an 
inherited predisposition ; intemperance in eating and drinking ; exces- 
sive physical or mental labor ; the use of tobacco ; venereal and other 
excesses; excessive anger; protracted grief; injuries of the spinal 
cord ; and various other causes of a kindred character. 

Nature. — This disease evidently consists in a weak or impoverished 
state of the blood, and an irritable condition of the nervous system, 
attended with deranged digestion, sanguification, and secretion. I 
believe, however, that the immediate cause of the excessive renal secre- 
tion, is an imperfect generation, and bad distribution of the nervous 
influence ; and hence it is that the excessive renal secretion is so often 
paroxysmal, following physical or mental excitement. 

In cases in which there is some permanent irritation along the middle 
or bower portion of the spinal cord, which is operating to produce the 
disease, an aggravation of the irritation from some accidental cause, 
may, and I believe often does produce sufficient derangement in the 
generation and distribution of the nervous influence, to cause for the 
time, the excessive renal secretion. 

The excess of urea may arise in part from a too exclusive animal 
diet, but the chyle and albumen, when present in the urine in such 
cases, I believe may be owing to imperfect sanguification growing out of 
derangement in the cerebro-spinal and nervous system. 

Treatment. — The indications in the treatment of this disease are, to 
correct the habits and regulate the diet of the patient, to restore the 
blood and nervous system, and to subdue any local irritation that may 
exist along the spine. 



LITHIASIS. 643 

The patient should keep the skin clean and warm, should take suit- 
able exercise, should preserve an even and cheerful temper of mind, and 
should be restricted to an almost exclusive vegetable diet. To correct 
the acidity of the stomach, a wineglassfull of lime water may be given 
each morning, and to regulate the bowels, a pill of aloes and rhubarb 
may be given at evening as long as may be required. 

To restore the blood, three or four grains of the carbonate of iron 
may be given three times per day, after each meal, and continued, if it 
agrees, till the blood is restored. If there is spinal irritation, cups 
should be applied occasionally at first, and later, pustulation may be 
produced by tartar emetic, either in the form of ointment, or else 
sprinkled on a conium, stramonium, or belladonna plaster, to be worn 
over the seat of the irritation. 

Having thus corrected the acidity, regulated the bowels, restored the 
blood, and subdued spinal irritation, if it existed, if the copious secre- 
tion of urine still continues, the drink should be rigidly restricted, and 
as a tonic to the nervous system, strychnia should be given. A grain 
of the muriate of strychnia may be dissolved in eight ounces of water, 
and of this a teaspoonful should be given after each meal, and continued 
till a cure is effected. 

SECTION VIII.— LITHIASIS— ( Gravel.) 

By lithiasis, from m0oj, " a stone," I mean here those insoluble de- 
posits which take place from the urine within the body, and also the 
peculiar conditions of the system upon which they depend. These de- 
posits generally depend upon either an acid or alkaline condition of the 
fluids of the body, and may be in the form of an impalpable powder, in 
crystalline particles like sand, or in solid concretions of various sizes. 

The deposits, whatever may be their form, may be included under the 
heads of the urates, the phosphates, and the oxalate of lime, and the con- 
ditions of the system upon which they depend, may be called the lithic, 
or uric acid diathesis, the phosphatic diathesis, and the oxalatie, or oxalic 
acid diathesis. 

Calculi are generally originally formed in the kidneys, from which 
points they pass along the ureters to the bladder, and are thence dis- 
charged through the urethra with the urine, or else being retained, they 
form by a gradual agglomeration of the pulvurent and crystalline parti- 
cles, solid concretions of various sizes. 

Of the urinary deposits, the lithic or uric acid appears to predomin- 
ate, and it very generally constitutes the central nucleus in other varie- 
ties of calculi. It is probable then that the deposition of uric acid is 
generally the primary process in the formation of urinary calculi, and 
that the phosphates, and oxalate formations are usually the result of a 
slow transition from the lithic acid to the phosphatic or oxalic forma- 
tions. This gradual transition from the lithic acid to the phosphatic 
and oxalic formations, is of course preceded by a change in the corres- 
ponding diathesis, the lithic acid diathesis being generally the primary, 
and this being succeeded by the phosphatic or oxalatic diathesis, or 
both. 



0*44 DISEASES OF THE URINARY ORGANS. 

Now bearing these facts in mind, we will proceed to consider the 
symptoms of lithiasis, gravel, or urinary calculi, first those which are 
common to all varieties, and then the symptoms peculiar to the lithates, 
or urates, the phosphates, and the oxalate of lime, and the corresponding 
diathesis upon which they depend in the order in which I have named 
them. 

Symptoms. — The symptoms of urinary calculi vary with the position 
they occupy, as they are liable to produce irritation in the kidneys, 
ureters, bladder, or urethra. 

Renal calculi, in addition to the symptoms of the diathesis upon 
which it depends, is attended with pain in the kidneys, with or without 
symptoms of inflammation of the kidneys and its attendant symptoms. 
The disease is sometimes accompanied with bloody urine, and may be at- 
tended with more or less febrile excitement or general nervous irritability. 

They are of various forms and dimensions, and generally consist of 
uric acid, animal matter, and oxalate of lime, with the phosphates in 
some cases. 

Calculi in the ureters, on their passage from the kidneys to the bladder, 
if sufficiently large or rough to produce irritation, cause, in some cases, 
the most excruciating pain along the ureters, extending to the testicle 
of the affected side in the male, and producing numbness of the thigh in 
both sexes. The pain in such cases is often of the most agonizing 
character, and the disease may be attended with bloody urine, and fol- 
lowed by the discharge of considerable fine crystalline particles, and 
perhaps small calculi, from the size of a pin's head to that of a pea, or 
larger. 

Vesical calculi, or stone in the bladder, whether they proceed from 
the kidneys, or as is more frequently the case, are formed by the 
agglomeration of crystalline particles around a nucleus of some kind in 
the bladder, are attended with various unpleasant and distressing symp- 
toms. There is a sense of weight in the perineum, and as the patient 
changes his position, there is sometimes a sensation as if a body were 
rolling in the bladder. There is a frequent desire to urinate, and often 
a sudden stoppage in its flow. Pain or an itching sensation is apt to 
be experienced at the extremity of the glans in men, and the disease is 
often attended with a discharge of bloody urine. 

Urethral calculi generally proceed from the bladder, and besides 
producing a tumor, if sufficiently large, obstruct the passage of urine, 
and if permitted to remain, cause pain, inflammation, fever, &c. 

Such, I believe, are the general symptoms common to all forms and 
varieties of urinary calculi in the kidneys, ureters, bladder, and 
urethra. We will now examine the symptoms peculiar to each variety, 
the urates, phosphates, and oxalate of lime, as well as of the diatheses 
upon which they depend. 

The lithic acid diathesis is characterized by an acid condition of the 
fluids of the body, attended often with a gouty or inflammatory ten- 
dency of the system. The deposit may occur from any cause which 
lessens the amount of urine, or from the use of acids, which, uniting 
with or neutralizing the alkaline principles of the urine, causes the 
deposition of lithic acid. 



LITHIASIS. 645 

The sediments which belong to this diathesis may be in the form of an 
impalpable powder, or in small crystalline particles, like sand, or else, 
as is sometimes the case, in small concretions. They are of a reddish, 
yellowish, or pink color, in consequence of certain coloring principles 
in the urine, and consist of either pure uric acid, or else the urate of 
soda mixed with a trace of the urates, of lime and ammonia. 

In cases in which these deposits take place in consequence of a 
decrease in the renal secretion, it is probably from an incapacity on the 
part of the urine to hold the deposited portion in solution or suspension, 
in consequence of which the deposition takes place, as we see in many 
inflammatory and fibrile affections. But when the deposits take place 
in consequence of acid food or drinks, it may be from the chemical 
changes produced, in consequence of which the uric acid is deposited, 
even though the secretion of urine continues undiminished, as we have 
already seen. The urine, however, in most cases of lithic gravel, is 
scanty and high colored, being passed frequently, and with more or less 
pain, and, as it cools, after being voided, a further deposition usually 
takes place, in consequence, probably, of its diminished solvent power 
at a reduced temperature. 

The lithic gravel is of a yellowish, pink, or reddish color, often 
adheres to the vessel in which the urine has been voided, and is 
readily dissolved by nitric acid, with effervescence, by which it may be 
distinguished, if necessary. 

Such, I believe, are the symptoms peculiar to the lithic acid diathesis, 
and to the depositions with which it is attended, which brings us to the 
consideration of the phosphatic diathesis and its depositions. 

The phosphatic diathesis is characterized by an alkaline condition of 
the fluids of the body, attended with an irritable condition of the nerv- 
ous system, and generally great derangement of the digestive organs, 
manifested by flatulence, nausea, constipation or diarrhoea, and a dull 
pain and feeling of weakness in the loins. In the worst cases, there is 
loss of appetite, a peevish and irritable temper, emaciation, a sunken 
and haggard appearance of the face, and often some organic disease of 
the urinary organs or spinal cord. 

The deposits in this diathesis consist of " the double phosphate of 
magnesia and ammonia, and the phosphate of lime, either separate or 
mingled," and appear either in the form of white crystalline grains, or 
else in an impalpable powder of a light yellowish appearance, or what 
is more common, there may be a mixture of the two forms in the de- 
posit. 

The urine in this diathesis is usually more copious than in health, 
being of a pale color when passed, and if clear at first, lets fall on cool- 
ing a sediment. If, however, the urine be allowed to stand for a con- 
siderable time, an iridescent pellicle of the phosphates appear on its 
surface, which is finally gradually deposited. 

A fit of gravel in this diathesis is comparatively rare, as the phos- 
phates are not very liable to be deposited within the body, even though 
the urine abounds in the salts. The phosphates may be distinguished 
by their whiteness, by their being generally deposited as the urine 
cools, by the pellicle which gradually forms on its surface, and is finally 



6±6 DISEASES OF THE URINARY ORGANS. 

deposited, and by their solubility in dilute acetic and muriatic acids. 
The phosphates are held in solution in the urine by an excess of acid, 
hence any cause which produces an excess of the salts or an alkaline 
state of the urine, causing their acids to be neutralized, may produce 
the phosphatic deposits. It appears probable that the alkaline deposits 
are generally associated with either functional or organic disease of the 
brain, or some portion of the nervous substance, and especially of the 
spinal cord. The alkaline state of the urine is also probably augmented 
in many cases, by various deranged conditions of the digestive organs. 

Such then, are the symptoms peculiar to the phosphatic diathesis, as 
well as those which attend its deposits, which leaves us only for con- 
sideration, the peculiar symptoms of the oxalatic, or oxalic acid diathe- 
sis, and its deposits. 

The oxalatic or oxalic acid diathesis consists in that peculiar condi- 
tion of the fluids of the body in which there is a tendency to the form- 
ation or deposition of oxalate of lime in the urine. It is attended with 
dyspepsia, nervous irritability, and a tendency to scaly eruptions, and 
to carbunculous affections. The patient is apt to be irritable, sensitive, 
feeble, hypochondriacal, and gloomy, and there appears to be a strong 
neuralgic tendency in most cases. 

The urine in this affection, is quite clear, exhibiting only a slight 
sediment on cooling ; but there is apt to be strong symptoms of calculus, 
along with the constitutional derangement. Oxalate of lime, may be 
crystalline or amorphous ; the crystals appearing under the microscope, 
transparent and octohedral, or in some cases circular or oval. It may 
be distinguished by its insolubility in acetic acid, and by its effervescence 
after calcination, with dilute acids. 

It is probable, that the oxalic deposit, may be favored by articles of 
diet, which contain oxalic acid, as the sorrel, the rhubarb, or pie plant, 
&c, and the free use of sugar may favor it, in those who are predisposed. 

Such then, are the general symptoms of lithiasis or gravel, and also 
the symptoms peculiar to the lithic acid, phosphatic, and oxalatic diatheses, 
as well as of the deposits belonging to each. 

Diagnosis. — Lithiasis or gravel, may generally be distinguished, 
whether the deposit be in the kidneys, ureters, bladder, or urethra, by 
pain in the part, of greater or less intensity, by the scanty, high-colored, 
and perhaps bloody urine, by the frequent and painful micturition, by 
the sediments of urates, phosphates, or the oxalates, which appear in the 
urine, and by the symptoms which attend on some one of the diatheses 
upon which the deposits depend. 

The presence of solid concretions, of considerable size in the bladder, 
may be distinguished by the evidences in most cases, of a gradual transi- 
tion from the lithic acid, to the phosphatic or oxalatic diatheses, by the 
sensation of something rolling in the bladder, on changing position, by 
the frequent and painful micturition, and sudden interruptions to the 
flow of urine, and finally by passage of a sound into the bladder, by 
which the stone may generally be felt. 

The urates may be distinguished from the other varieties of gravel, by 
the existence of the lithic acid diathesis, with the acid condition of the 
fluids of the body, a dyspeptic, and inflammatory tendency, and by the 



LITHIASIS. 647 

pink or reddish appearance of the sediment, which is readily dissolved 
by nitric acid, with effervescence. 

The phosphates may be distinguished by the existence of the phos- 
phatic diathesis, with an alkaline condition of the fluids of the body, 
attended with dyspepsia, and generally with organic or functional de- 
rangement of the nervous system, and especially of the spinal cord. 
The deposits are white, take place generally as the urine cools, and if 
the urine is allowed to stand, an iridescent pellicle of the phosphates 
form upon its surface, which, however, gradually subsides. The phos- 
phates are soluble in dilute acetic and muriatic acids. 

The oxalate of lime, may be distinguished by the oxalatic diathesis, 
with the dyspeptic, irritable, hypochondriacal, and gloomy condition, 
and the tendency to scaly eruptions, carburculous affections, &c. 

The deposits may be distinguished by the transparent octohedral, cir- 
cular, or oval appearance of the crystals, under the microscope, and by 
its insolubility in acetic acid, but ready effervescence, after calcination, 
with dilute acids. 

By careful attention to all these diagnostic symptoms, we may not 
only distinguish a case of lithiasis or gravel ; but readily distinguish the 
different varieties, as well as the diathesis, upon which they depend. 

Causes. — The direct causes of the disposition of the urates, phos- 
phates, and oxalate of lime, are the lithic acid, phosphatic, and oxalatic 
diatheses, upon which they depend, together with some occasional acci- 
dental circumstance. In arriving at the cause of this disease, in its 
various forms then, we have to inquire mainly into the causes of the 
various diatheses, taking into account, the accidental circumstances, 
which occasionally operate to increase the deposits. 

The lithic acid diathesis may be produced by a variety of causes, but 
it is probable that the most frequent are a too free use of high-seasoned 
animal food, the use of alcoholic drinks, in their various forms, and 
indolent habits, in consequence of which the stomach is over-taxed, and 
too much azotized matter introduced into the system. 

With the fluids of the body thus brought into an acid state, the 
lithates may be deposited, more or less, continually ; but, let the urine 
be rendered scanty, from some inflammatory or febrile affection to which 
the system is always predisposed in such cases, and a copious deposi- 
tion of the lithates takes place, from the inability on the part of the 
urine to hold them in solution. A copious deposition of the lithates 
may also be produced, when this diathesis prevails, by the use of acid 
food or drinks, probably in consequence of their neutralizing alkaline 
principles, which had helped to hold the lithic acid or lithates in solu- 
tion in the urine. 

The phosphatic diathesis may be produced by local injuries of the brain 
or spinal cord, but it is generally brought about by want, exposure, 
overtaxing the body or mind, licentiousness in its various forms, and 
various other influences which produce organic or functional disease of 
the nervous system, and especially of the spinal cord. 

As the phosphates are held in solution in the urine by an acid, any 
accidental increase in the nervous derangement, which produces an 
excess of the salts, or an alkaline state of the urine, may, by neutral- 
izing the acid, cause a deposition of the phosphates. 



648 DISEASES OF THE URINARY ORGANS. 

The oxalatic, or oxalic acid diathesis, may be caused by improper food, 
irregularity of eating, and various imprudences, which impair digestion, 
and render the patient nervous, irritable, neuralgic, gloomy, hypochon- 
driacal, &c. It is probable that there is generally an excess of urea in 
oxalic acid urine ; and in cases in which the oxalatic diathesis prevails, 
it is likely that the oxalic deposit is increased or favored by the use 
of vegetables which contain oxalic acid, as the sorrel, rhubarb, or pie- 
plant, &c. 

Now, having traced the various causes which produce the different 
diathesis, as well as the accidental influences which particularly favor 
or increase the deposit at times, producing a fit of gravel, we have yet 
to inquire into the influences which operate in producing solid concre- 
tions or stone in the kidneys or bladder, but generally in the bladder. 

We have already seen that the deposition of lithic acid, or the 
lithates, is generally the primary process in the formation of urinary 
calculi ; and it is probable that the phosphate and oxalate formations, 
which often go to make up the great bulk of the calculi, are the result 
of a gradual transition from the lithic acid to the phosphatic, or oxalatic 
diathesis. 

In conversation a few years since with the late Dr. Amasa Trow- 
bridge, of Watertown in this State, who had operated, I believe, some 
fifteen or sixteen times for stone in the bladder, in Northern New York, 
in a region where the water is generally largely impregnated with lime, 
he observed that all, or nearly all his cases had been persons that had 
removed to that lime region, from localities in which the water was un- 
impregnated with lime. And as the Doctor had made this observation 
during a long term of years, it appears probable that the constant use 
of lime, as it exists in the water in lime-stone regions, if commenced at 
infancy and continued through life, tends strongly to prevent a lithic 
acid diathesis and deposit, and hence is a partial security against the 
formation of urinary calculi of all kinds, as the primary nucleus is 
wanting. But the observation appears to show further, that in persons 
born and brought up in regions where the water contains no lime, the 
lithic acid diathesis and deposits are very common ; and that if such 
persons remove to a lime region, and the diathesis becomes changed 
from some cause to the phosphatic or oxalatic, if the lithates exist in 
the bladder in the form of concretions, to afford a nucleus, around 
which the phosphates and oxalate, as the diathesis changes, may readily 
unite by agglomeration, calculi of large size may form requiring an opera- 
tion for their removal. In cases, however, in which concretions of the 
lithates had not formed, and the phosphatic or oxalatic diathesis is not 
produced by some accidental cause, it appears probable that the use of 
the lime in such cases, may generally correct not only the lithic acid 
lithiasis, but also the diathesis upon which it depends. 

Prognosis. — The prognosis in recent cases of lithiasis or gravel, is 
rather favorable if the cause can be removed and the patient be sub- 
jected to proper treatment. In protracted cases, however, in which the 
digestive organs and the nervous system are seriously involved, restora- 
tion to perfect health, if accomplished at all, must be slow at best, and 
not unfrequently the disease or its complications may lead on to a 
fatal termination. 



LITHIASIS. 649 

Treatment. — The treatment of lithiasis divides itself into that which 
is proper for the expulsion of deposits from the kidneys, ureters and 
bladder ; and that which is indicated from the correction of the general 
condition, and the different diatheses upon which the deposits depend. 

In cases then in which the patient is found with evidence of gravel in 
the kidneys, the free use of mucilaginous drinks may be allowed, and 
the patient may be directed to take some exercise by walking or riding, 
with the hope of favoring its passage into and along the ureters. 

If, however, calculi have passed into and become lodged in the 
ureters, and the patient is found suffering the most excruciating pain 
along the ureters; in addition to mucilages, cups and fomentations of 
hops, and the warm hip-bath if necessary ; ten drops each of sulphuric 
ether and oil of turpentine may be given every six hours, with the hope 
of producing relaxation of the ureters ; and if necessary, alternating 
with this, fifteen drops of the fluid extract of hyoscyamus may be 
given to quiet pain. 

Finally, if the bladder is the seat of the calculi, and there is hope 
that it may admit of being passed through the urethra, the patient 
should take mucilages freely, retain the water in the bladder as long as 
it can be conveniently, and then bending the body forwards, so as to 
bring the calculi as near the commencement of the urethra as possible, 
should allow the urine to pass in a full stream, with the hope that the 
calculi may thus be brought away with the urine. 

Having thus made an effort to relieve the immediate suffering, in 
cases in which the patient is first seen during a fit of gravel, and at 
first, in cases of lithiasis examined at other periods, the habits and 
general condition of the patient should be ascertained, and the case 
treated on strictly common sense principles. 

The habits of the patient should be corrected at once, and every 
cause or influence which might be supposed to operate either directly or 
indirectly to produce or keep up the disease, should be carefully re- 
moved, as far as possible. 

The patient should be directed to keep the skin clean, to wear flannel, 
and sleep in flannel sheets, to take suitable exercise, and also proper 
food, with strict regularity, and to be strictly temperate and prudent 
in all things. If the bowels are constipated, they should be regulated 
by cathartics or laxatives suited to each particular case. And if the 
blood is weak, and the nervous system prostrated, some preparation of 
iron, and perhaps strychnia, in small doses, may be required. 

By thus removing the cause, and correcting the habits and general 
condition of the patient, the lithiasis and diatheses upon which it de- 
pends, may sometimes be removed, or at least the progress of the dis- 
ease may be arrested. If, however, it becomes necessary to do more, 
as it very generally may, remedies should be varied according to the 
prevailing diathesis and character of the deposit. 

If the lithic acid diathesis prevails, with its peculiar deposits, the 
patient should be restricted mainly to a vegetable diet, to lessen the 
amount of urea in the system, and to render the uric acid more soluble ; 
and at the same time to correct the acid condition of the fluids of the 
body, alkalies should be administered. Of the alkalies, the bicarbonate 



650 DISEASES OF THE URINARY ORGANS. 

of soda or potassa will generally do best. Half a drachm of either may 
be given four times per day, dissolved in not less than four ounces of 
water, and continued till the urine ceases to yield a deposit, and the 
acid condition of the fluids of the body are corrected. 

In slight cases, however, if the bowels are constipated, twenty grains 
of magnesia may be given, morning and evening, and continued as long 
as may be required, instead of the potassa or soda, already suggested. 
Or in cases attended with diarrhoea, four ounces of lime-water may be 
given, three times per day, after meals, and continued as long as may 
be required. 

While this alkaline treatment is being pursued, if the patient is an- 
noyed by small concretions in the bladder, a drachm of the fluid ex- 
tract of the hydrangea arborescens may be given, three times per day; 
till the concretions pass, when it should be omitted, and the alkali con- 
tinued, if necessary. 

If the phosphatic diathesis prevails, however, with its deposits, the 
patient should take a diet mainly of animal food, and instead of alka- 
lies, should take either the sulphuric, nitric, muriatic, or benzoic acid, 
well diluted. I prefer the muriatic acid in most cases, of which ten 
drops may be given, diluted with six or eight ounces of water or thin 
gruel, after each meal, and continued as long as may be required. If 
there is spinal irritation, it should be subdued by cups, blisters, &c, 
and while the acids are being administered, as a tonic and astringent 
for the urinary passages, half a drachm of the fluid extract, or an ounce 
of the infusion of uva ursi may be given four times per day, with the 
addition, when necessary, of fifteen drops of the fluid extract of hyos- 
cyamus, as an anodyne. 

Finally, if the oxalatic, or oxalic acid diathesis, with its deposit pre- 
vails, the patient may be allowed a mixture of animal and vegetable 
food, but should avoid such vegetables as contain oxalic acid, as the 
the rhubarb or pie plant, &c, and should not indulge too freely in the 
use of sugar, in any form. 

To correct the oxalatic diathesis, four drops of the nitromuriatic acid 
may be given, three times per day, after each meal, diluted in at least 
six ounces of water, and continued till uric acid is deposited in the urine, 
in place of oxalate of lime, when it should be discontinued, and half a 
drachm each of the fluid extract of hydrangea and uva ursi given in- 
stead, till a cure is effected. 

SECTION IX.— SUPPRESSION OF URINE. 

By suppression of urine, I mean here a partial or complete suspen- 
sion of the renal function, so that little or no urine is secreted. 

This condition, whether the suppression be partial or complete, is 
generally the result of inflammation, paralysis, or organic disease of 
the renal glands, which of course varies the symptoms which are de- 
veloped. 

Symptoms. — In cases of suppression from inflammation of the kid- 
neys, the diminution or entire suspension of the urinary discharge, 
follows the ordinary symptoms of nephritis, such as pain in the lumbar 



SUPPRESSION OF URINE. 651 

region, nausea, vomiting, &c. Very soon after the renal secretion 
ceases however, the patient becomes torpid and dull, the pulse may 
become slower than in health, a urinous odor exhales from the surface 
of the body, and finally there is the supervention of drowsiness, mental 
wandering, coma, convulsions, and death. 

In cases which occur from paralysis of the kidneys, the suppression 
may be attended with little or no pain, there being at first only a feel- 
ing of restlessness, with perhaps slight uneasiness in the lumbar region. 
Soon, however, nausea and vomiting may occur, and gradually there is 
the supervention of dullness, drowsiness, hiccough, coma, and convul- 
sions ; and finally, if the condition continues, a fatal termination is the 
result. 

In cases of suppression, from organic renal disease, in addition to the 
symptoms belonging to the organic affection, there is the supervention 
of those enumerated above, the result probably of the accumulation of 
urea in the blood, and its effect upon the brain and nervous system. 

In all cases of suppression of urine, in addition to the urinous smell 
of the cutaneous exhalation, there is apt to be the same odor from the 
alvine discharges ; and there is not unfrequently a urinous taste in the 
mouth. And unless this vicarious discharge is sufficient to relieve the 
blood of the urea which is fast accumulating, the patient may generally 
die by the third or fourth day after the entire suspension of the renal 
function. 

This affection may be distinguished from retention of urine by the 
empty state of the bladder ; whereas in that affection it becomes dis- 
tended, forming a tumor, which may readily be felt above the pubis. 

Causes. — The direct causes of suppression of urine, as we have 
already seen, are nephritis, paralysis, and organic renal disease. 

Renal inflammation, as we have seen in a preceding section, may be 
produced by a variety of causes ; such as direct injuries, exposure to 
cold, stimulating diuretics, &c. 

Renal paralysis may be produced by any cause, or train of causes, 
which prevents the generation of sufficient nervous influence, or hinders 
its distribution to the renal glands. It is probable that various causes 
may operate, such as fatigue, spinal injuries, &c, in bringing about this 
deplorable state ; but I believe that is more generally the result of 
venereal excesses, protracted drunkenness, and the use of tobacco. At 
least such has been the result of my observation. 

Organic renal diseases, as we have already seen in a preceding sec- 
tion, may be caused by an inherited or acquired depraved condition of 
the system ; almost every deviation from the laws of health operating 
to excite, aggravate, or perpetuate the disease. 

Thus we have at a glance the most frequent direct and remote causes 
of suppression of urine ; which it may be well to bear in mind, as we 
proceed to the consideration of the treatment for this most distressing 
or dangerous affection. 

Treatment. — In inflammatory cases the treatment should be that ordi- 
narily indicated for nephritis, such as bleeding, cupping, fomentations, 
hyoscyamus, cream of tartar, sweet spirit of nitre, &c, which, if judi- 
ciously applied, will generally do all that may reasonably be anticipated 
in such cases. 



652 DISEASES OF THE URINARY ORGANS. 

In cases depending upon renal paralysis, spinal irritation may require 
cups, blisters, &c. In addition to this, strychnia may be given as a 
nervous tonic, and, to stimulate the kidneys into activity, twenty drops 
of the oil of turpentine may be given every two hours, till the renal 
function is resumed. 

In cases depending upon organic renal disease, those palliative mea- 
sures only should be resorted to which each particular condition may 
suggest, as a permanent cure is not to be expected in such cases. 

SECTION X.— RETENTION OF URINE. 

By retention of urine is here meant an obstruction to the passage of 
urine after its secretion, whether that obstruction be in the ureters, 
bladder or urethra. 

As the urine, after its secretion in the kidneys, has to pass along the 
ureters to the bladder, and from thence through the urethra, in being 
voided, it is not strange that its progress should be interrupted by 
calculi or coagula in the ureters, by inflammation or paralysis of the 
bladder, or by spasms or other obstruction of the urethra. 

Retention occurring from obstruction at either of these points, from 
various causes or conditions, is attended with a train of symptoms, which 
we will now proceed to consider. 

Symptoms. — Renal retention, whether it be from calculi, coaguli, or 
spasm obstructing the ureters, is attended with a sense of weight, pain, 
and distension in the lumbar region ; and if the obstruction continues, 
the loins become tender, the kidneys and ureters above the obstruction 
become enormously distended, producing a tumor which may sometimes 
be felt, and unless relief be afforded, inflammation of the parts, with 
disorganization and a fatal termination, is the result. 

Vesical retention, if from cystitis, is attended with the ordinary symp- 
toms of inflammation of the bladder, such as pain, tenderness, nausea, 
vomiting, fever, &c, and, in addition, there is the tumor caused by the dis- 
tended bladder, which may readily be felt above the pubis, reaching, in 
some cases, the umbilicus, or even the scrobiculus cordis. If, however, 
the retention be from paralysis of the bladder, there may be little or no 
pain at first ; but as the bladder becomes distended, the pain, as in all 
other cases, becomes more or less severe, and unless relieved, the patient 
becomes anxious, restless, feverish, and exceedingly distressed, until the 
bladder finally gives way, and a fatal termination is the result. 

Finally, if the retention be from spasms or other obstructions of the 
urethra, in addition to the symptoms enumerated above, there is pain 
along that passage, and if a stone has become lodged in it, a tumor 
may be felt in many cases, an interesting instance of which fell under 
my observation a few years since. 

Such, I believe, are the ordinary symptoms of retention of urine, 
whatever be the seat or nature of the obstruction. 

Diagnosis — Retention may be distinguished from suppression of urine 
by the distension of the bladder which occurs, if it be vesical, or of the 
kidneys and upper portion of the ureters, if it be renal. 

Vesical retention may be distinguished from renal by the fullness of 



DYSURIA. 058 

the bladder, and cases occurring from urethral obstruction, by the 
evidence which exists of stone in, or spasms of, that passage. 

Causes. — The most frequent causes of renal retention are calculi, or 
coagula of blood or fibrin, in the ureters. 

The obstruction may take place, however, from thickening or spasm 
of the ureters, or from tumors pressing upon them from without. 

Vesical retention may be caused by inflammation of the mucous mem- 
brane of the bladder, closing the opening of the urethra, by paralysis of 
of the bladder, or by spasms or other obstructions of the bladder or 
urethra. 

Treatment. — In cases of renal retention, attended as it may be with 
nephritis, bleeding, cupping, fomentations, the warm bath, saline cathar- 
tics, anodynes and antispasmodics may be required, and should be 
judiciously applied, while the least hope of relief remains. 

In vesical retention from inflammation of the bladder, nearly the same 
general treatment is required, and in addition an effort should be made 
to pass the catheter, should the bladder become very much distended, 
and if successful, the water may be thus drawn off two or three times 
per day, till the inflammation subsides, and the obstruction is overcome. 
And should there be evidence of spasm of the bladder, tending to close 
the opening of the urethra, ten drops of the tincture of stramonium may 
be thrown into the rectum, with an ounce of mucilage of gum arabic, or 
the same quantity of liquid starch, and a fomentation of stramonium 
leaves may be applied and carefully watched, externally with the hope 
of relaxing the vesical spasm. 

In cases in which the retention is from paralysis of the bladder, the 
catheter should be introduced and the water drawn off, two or three 
times per day, and general and local measures immediately taken to 
overcome the paralysis. If there is spinal disease, cups, blisters, &c, 
should be applied, and the local irritation subdued. This being accom- 
plished, if the paralysis continue, strychnia may be given in ■£$ of a 
grain doses three times per day, before each meal, as a nervous tonic, 
and as a stimulus to the bladder, twenty drops of the tincture of can- 
tharides may be given after each meal, and this treatment may be con- 
tinued till the paralysis is overcome. 

Finally in cases depending upon stricture of the urethra, the warm 
hip-bath, stramonium fomentations, and the internal administration of 
the tincture of stramonium and tincture of chloride of iron, of each ten 
drops every one, two, or three hours, as long as it may be safe, will 
generally do most, and if this should fail, an effort may be made to pass 
a small bougie, and then a catheter, and failing in this, the bladder 
should be punctured to avoid a worse result. 

SECTION XL— DYSUKIA— [Strangury.) 

By dysuria, from 5t?, "with difficulty," and ovpo^ "urine," I mean 
here difficult and generally painful micturition without any considerable 
retention. 

Dysuria or strangury may depend upon a permanent irritation of the 
bladder or urethra, or it may be transient, the result of irritating pro- 



654 DISEASES OF THE URINARY ORGANS. 

perties in, or an acrid state of the urine, and in either case there may 
be but trifling if any retention. 

Symptoms. — In permanent cases, there is sometimes a constant feel- 
ing of weight, fullness or heat in the neck of the bladder, this irrita- 
bility causing a frequent call to urinate during which there is pain, and 
the water may pass tardily, or in a small stream, but does not accumu- 
late. 

In transient cases in which the urine is rendered acrid from some 
cause, the calls to urinate may be less frequent, and the water may pass 
more freely, but it is attended with pain or a burning sensation along 
the urethra, and especially in its posterior part. 

Causes. — Various causes may operate to produce this affection 
among the most frequent of which are excesses in eating, the use of 
spirituous liquors, irritating diuretics, masturbation, onanism, and ex- 
cessive venery, acid food, or drinks, hemorrhoids, ascarides in the rec- 
tum, suppressed catamenia, vesical calculi, leucorrhosa and gonorrhoea, 
and repelled cutaneous affections. 

Treatment. — In slight cases of strangury, depending upon irritation 
of the neck of the bladder, with or without an acrid state of the urine, 
produced by blisters, cantharides taken internally, or any other acci- 
dental causes ; a dose of castor oil, the free use of mucilages, and fifteen 
drops of laudanum thrown into the rectum, with an ounce of flax-seed 
tea, will be sufficient to produce relief in most cases. 

In more permanent cases, however, in addition to mucilages, a regu- 
lated diet, and removal of the cause, a drachm of the fluid extract, or 
an ounce of the infusion of buchu may be given three times per day, 
and continued till the irritation of the bladder and urethra are subdued. 
If, however, the patient is anaemic, and there still remains a disposition 
to spasm of the bladder or urethra, after the catarrhal condition is- sub- 
dued, ten drops of the tincture of chloride of iron should be given in 
mucilage, three times per day, after meals, and continued till the blood 
is restored, and the tendency to spasm is overcome. 

If the strangury appears to be the result of a deposit of lithates in 
the urine, alkalies should be given ; if of the phosphates or oxalate, acids, 
and if there is evidence of small vesical concretions, a drachm of the 
fluid extract of hydrangea may be given for a while, three times per 
day, with the hope of promoting their passage, and thus relieving the 
irritation. 

SECTION XII.— INCONTINUANCE OF URINE. 

By incontinuance of urine, is here meant an inability to retain the 
urine, in consequence of which it is passed involuntarily, either con- 
stantly, by drops, as it is secreted, or else after considerable has been 
accumulated. 

Symptoms. — In cases in which the urine is passed by drops, as it is 
secreted and poured into the bladder, the dribbling keeps up constantly, 
day and night, unless accidentally interrupted, for a little time, by posi- 
tion in sitting or lying. But in cases in which considerable accumulates 
before it passes off; the patient during the day, is only troubled by the 



INCONTINUANCE OF URINE. 655 

inconvenience attending frequent micturition, as a slight voluntary effort, 
may enable the patient, in many cases, to void the urine, before the in- 
voluntary discharge takes place. In such cases, however, nocturnal dis- 
charges occur, while the patient is asleep, which are exceedingly 
annoying. 

In other cases still, especially in children, there is but little, if any 
apparent inconvenience during the day ; but almost invariably a discharge 
during the night, and this may be kept up for months, or even years, 
and become a source of great vexation, to both parent and child. 

Causes. — Incontinuance of urine, may be the result of a paralysis of 
the sphincter of the bladder, in consequence of which the neck of the 
bladder is constantly relaxed, affording no obstruction to the passage of 
the urine ; the patient in such cases, having no power to control it. In 
other cases, the incontinuance may depend upon an irritable state of the 
bladder, in consequence of which, the urine is passed, in spite of the 
sphincter. Or the vesicle irritation may exist, with paralysis of the 
sphincter, and thus the incontinuance be produced. I believe, however 
that in nocturnal incontinuance, as it occurs with children, it is gener- 
ally from a want of sufficient excitability in the neck of the bladder, in 
consequence of which, the urine is allowed to pass, during sleep, without 
exciting the sphincter to contraction. 

Treatment. — In cases .of incontinuance, depending upon irritation of 
the bladder, the cause should be sought out, and removed, and the irri- 
tation subdued by counter-irritants, mucilages, astringents, &c. If, as the 
vesical irritation is subdued in such cases, there is evidence of paralysis, 
and in all cases of paralysis, without vesical irritation ; spinal irritation 
should be subdued, if it exists, and then strychnia administered, in small 
doses, till the paralysis is overcome. Finally, in cases of nocturnal in- 
continuance, as it occurs in children, from a want of due excitability in 
the neck of the bladder, tincture of cantharides should be given, in 
moderate doses, three times per day, and continued till the condition is 
corrected, when the incontinuance will generally cease. 






CHAPTER XV. 

DISEASES OF THE GENITAL ORGANS. 



SECTION—I. SPERMATORRHEA. 

By spermatorrhoea, from antp/xa, "sperm," and p?w, "I flow," is here 
meant an emission of sperm, without copulation, whether diurnal or 
nocturnal, the result very generally of masturbation, onanism, or vene- 
real excesses. 

I design also to include under this head that morbid condition into 
which the female system is brought by excessive sexual indulgence, and 
masturbation, or excitement of the genital organs by the hand. 

Now in order to understand this disease, as it occurs in both sexes, 
it is necessary that the anatomy and physiology of the male and female 
genital organs should be well understood, as well as their direct and 
sympathetic relations. We will, therefore, take a general glance, first 
at the female and then at the male organs of generation, leaving the 
examination of each part for consideration, as we take up the diseases 
to which they are liable, in the following sections of this chapter. 

The female genital organs, it should be remembered, consist of the 
vulva, vagina, uterus and ovaries. The womb, with its appendages, the 
ovaries, fallopian tubes, round and broad ligaments, and composed of 
its external serous internal mucous, and middle muscular tunics or coats, 
is situated in the middle of the cavity of the pelvis, between the bladder 
and rectum, beneath the convolutions of the small intestines, being con- 
tinuous below with the vagina. 

The vagina is a membranous canal, leading from the uterus to the 
vulva, passing between the bladder and rectum, and corresponding in 
direction with the axis of the outlet of the pelvis. It is five or six 
inches in length, is composed of an internal mucous lining, a middle 
layer of erectile tissue, and an external contractile fibrous tissue, and is 
attached superiorly to the cervix of the uterus, which projects into the 
upper extremity of the canal, and is continuous below, by its mucous 
membrane with that of the vulva. 

The vulva or external organs of generation in the female, includes 
the mons veneris, labia majora, labia minora, clitoris, meatus urinarius, 
and opening of the vagina, parts situated at and about the entrance of 
the vagina, which is the primary seat of the local irritation in the mas- 
turbation of females. This fact should be borne in mind, but a further 
description of the parts are unnecessary for our present purpose. 

The male genital organs, consist of the penis, the testicles and their 
appendages, and the seminal vesicles, a general glance at which is 
necessary as we proceed, in order to understand the symptoms which 
are developed in this disease. 



SPERMATORRHOEA. 657 

The penis, consisting of a root, body, and extremity, or glans, is 
composed of the corpus cavernosum, corpus spongiosum, and an invest- 
ing membrane, which is loosely attached to the entire surface, except 
the glans, over which the extremity of it, called the prepuce, readily 
passes, when the organ is in a quiescent state. At the extremity of the 
glans is the meatus urinarius, or opening of the urethra, which is a 
membranous canal, extending back to the neck of the bladder, having a 
lining mucous and external fibrous coat. 

That part of the urethra which extends from the meatus urinarius, 
through the corpus spongiosum, to the deep perineal fascia, is called 
the spongy portion', that part, about an inch in length, immediately 
back of this, which passes between the two layers of the deep perineal 
fascia, is called the membranous portion, while the remaining posterior 
part of the urethra, about an inch in length, which passes through the 
prostate gland, above its middle, back to the bladder, is called the 
prostatic portion. The mucous coat of the urethra is thin and smooth, 
and continuous externally, with the investing membrane of the glans, 
internally with the mucous membrane of the bladder, and at interme- 
diate points with the lining membrane of the ducts of Cowper's glands, 
the prostate gland, of the vasa deferentia and vesiculse seminales. 

Cowpers glands are two glandular bodies, the size of a pea, situated 
on the sides of the urethra, near the junction of its spongy and mem- 
branous portion, with each a short excretory duct, emptying obliquely 
into the urethra. 

The prostate gland is situated in front of the neck of the bladder, 
upon the rectum, and behind the deep perineal fascia, and surrounds 
the urethra for about an inch, to the membranous portion. The urethra 
passes through the gland above its middle, and it is traversed near its 
inferior surface by the ejaculatory ducts of each side. The gland is of 
a conical form, the base being directed posteriorly; it has three lobes, 
two lateral and a middle, and is composed of numerous follicles, which 
give origin to ten or fifteen excretory ducts, which open into the urethra. 

The vesiculse seminales are two membranous reservoirs, about two 
inches in length, and six or seven lines broad, situated beneath the 
bladder and above the rectum, their larger extremities being directed 
backwards and outwards, and their smaller inwards and forwards, almost 
meeting at the base of the prostate gland, through which their ducts 
pass, having united with the vasa deferentia, constituting the ejaculatory 
ducts. The ejaculatory ducts thus formed, by a union with the vasa defe- 
rens of each side, pass along through the inferior portion of the pros- 
tate, for about three fourths of an inch, and open near each other into 
the urethra. 

The testicle, a right and left, occupying the scrotum, and composed of 
the tubuli testis, the vasa recta, the rete testes, the vasa efferentia, &c, 
is the organ for the secretion of the sperm. The sperm secreted in this 
delicate structure of the testicle, passes out of the gland by the vasa 
efferentia to the epididymus, an appendage of the testicle, and through 
this to its termination in the vas deferens. From the epididymus, the 
vas deferens passes with the spermatic artery, veins, and nerves, consti- 
tuting the spermatic cord, as far as the internal abdominal ring. At 
42 " " " 



658 DISEASES OF THE GENITAL ORGANS. 

this point, having entered the abdomen, the vas deferens leaves the 
other portion of the spermatic cord, being reflected inwards to the side 
of the fundus of the bladder, and extending along its posterior surface, 
passes along the internal side of the vesicula seminalis to the base of 
the prostate gland. At this point, it unites with the duct of the vesi- 
cula seminalis, constituting, as we have already seen, the ejaculatory 
duct. The ejaculatory duct thus formed, by the junction of the duct of 
the vesicula seminalis with the vas deferens, passes, as before suggested, 
about three-fourths of an inch through the inferior portion of the pros- 
tate, till it reaches the urethra, into which it empties near that of the 
opposite side. 

Now, in a healthy state of the genital organs, no semen is secreted by 
the testicles, except during sexual intercourse, and then the sperm passes 
along each vas deferens into the ejaculatory ducts, and thence into and 
through the urethra to the cavity of the vagina or womb. 

It is possible, however, that occasional nocturnal seminal discharges 
may occur, in an ordinary state of health, from a lively dream, in 
which the imagination provokes the seminal secretion and discharge. 
Such an occurrence, in a normal state of the genital organs, should not 
take place, however, oftener than once in three or four weeks, if at all. 

When, however, the sexual organs are rendered morbidly irritable 
by any local disease of the parts, from masturbation, onanism, or 
excessive sexual indulgence, the blood vessels become congested, the 
whole glands become irritable, and a morbid secretion of semen is liable 
to take place. Now, this morbid seminal secretion may be quite con- 
stant, in which case the sperm, passing into the ejaculatory ducts, 
through each vas deferens, either passes into the urethra and is voided 
with the urine, or gradually dribbles away, or else it passes from the 
ejaculatory ducts back into the vesiculse seminales, and there accumu- 
lates. In this case it is apt to be discharged at each movement of the 
bowels, by the mechanical pressure of the alvine evacuation, pressing 
from the rectum upon the vesiculse seminales, or having accumulated 
in the vesiculse seminales, it may then excite an erection, with the aid 
of a dream, which it may also provoke, and thus be thrown off as a 
nocturnal discharge. 

Hence morbid seminal discharges may be diurnal, the semen passing 
off by degrees, or with the urine, or at each movement of the bowels, or 
they may be nocturnal, the morbid irritability producing an erection, 
and, perhaps, affecting the brain sympathetically, provokes a dream, 
during which a discharge of semen takes place. In some cases of this 
character the dream and sensation are remembered, in others the dream 
only, while in very bad or protracted cases, neither the dream or sensa- 
tion is remembered, the patient only being aware of the discharge by 
its presence on the bed-clothes as he awakes. 

Now, these involuntary seminal discharges may continue for a short 
time, if slight, without producing any very marked constitutional or 
general symptoms. But if the morbid seminal discharges be considera- 
ble, and are continued for any great length of time, the most serious 
constitutional effects follow; and the same is also true with females, 
if the genital organs are rendered irritable, as they sometimes are, by 






SPERMATORRHOEA. 659 

masturbation or titillation, though in this case there is of course no 
wasting discharge. The patient in such cases, whether male or female, 
becomes weak, nervous and irritable, the eyes are sunken, the counte- 
nance becomes pale, and there is eventually great debility of the nervous 
system. The brain becomes incompetent to supply sufficient nervous 
influence to enable the various organs of the body to carry on their 
functions in a proper manner, and hence we have arising a train of 
symptoms, in both sexes, which we will now proceed to consider. 

Symptoms. — In addition to the pale face, sunken eyes, and haggard 
expression of countenance, digestion becomes impaired, and each meal, 
besides being taken with a poor relish, is followed by a sense of weight 
in the epigastrium, and more or less uneasiness and restlessness. This 
gastric disturbance after taking food, is apt to be attended with a quick- 
ened pulse, a flushed face, confusion of the ideas, ringing in the ears, 
vertigo, and sometimes with symptoms of cerebral congestion, which 
may threaten apoplexy. 

This morbid condition or action of the stomach gradually increases, 
so that the food taken, being imperfectly digested, passes into the 
duodenum in a crude state, where it produces more or less irritation. 
And as the liver, too, from the same cause, is in a torpid state, an 
insufficient amount of bile is secreted or furnished to change the imper- 
fect chyme into chyle, so that an insufficient quantity of imperfect 
chyle only is supplied to the system, and hence the emaciation. The 
passage of this illy digested food produces irritation of the alimentary 
mucous membrane, and, as a consequence, acid eructations, colic pains, 
and constipation is apt to follow. 

Now, this constipation of the bowels frequently produces hemorrhoids 
or piles, and in consequence of the increased irritation in these parts, 
the spermatorrhoea, or irritation of the male or female genital organs, 
is increased or kept up, even though the other causes should be removed. 

The imperfect digestion cuts off nutrition, so that the general debility 
is greatly increased, nervous irritability increasing, as well as local 
irritability of the genital organs, and so the disease progresses, the 
seminal disease in the male being gradually increased, as well as local 
and constitutional disturbance in the female. 

In consequence of the general debility, want of vital energy, and bad 
distribution of the nervous influence, the respiration becomes imper- 
fect, the patient being out of breath, from slight exercise, as from 
ascending a hill, a flight of stairs, &c. As the disease progresses, nervous 
or sympathetic palpitation of the heart is apt to occur, in some cases 
being of the most distressing character, developing symptoms, in many 
respects similar to those which attend organic cardiac disease. 

Patients suffering from this affection become weak, even before they 
lose much flesh, in consequence of the nervous prostration. Sensation, 
too, in many of these cases, becomes extremely low in the extremities, 
especially in the hands, and the sense of taste, smell, hearing, and sight, 
all are liable, sooner or later, to become impaired, the eye losing its 
natural brilliancy, being sunken, and surrounded by a dark circle. The 
pupils are generally dilated, and amaurosis is very liable to occur ; 
sometimes, however, there is great intolerance of light, the pupil being 



660 DISEASES OF THE GENITAL ORGANS. 

very much contracted. There is, too, in this affection, always an 
expression of shame, the eyes seldom if ever meeting those of another 
with confidence, being turned away hastily, and after wandering about 
for a moment, are at length turned to the ground. 

The brain, after a time, becomes very seriously involved, the ideas 
being confused, and memory weak, and the sleep, at first interrupted 
and unrefreshing, becomes gradually less, till the patient gets but Mttle 
sleep, and that of an unnatural character. 

The patient gradually becomes desponding and melancholy, and in 
many cases there is a distrust of every one, and a strong inclination to 
commit suicide. Congestion of the brain is liable to occur from slight 
causes at first, and, as the disease progresses, chorea, catalepsy, epilepsy, 
or apoplexy may be the result. 

Patients suffering from this disease are always hypochondriacal, being 
nervous, irritable and excitable, from slight causes. They are apt to 
dwell constantly on their sufferings, and are almost sure to forget every- 
thing else, very much like a person in advanced age. 

In consequence of the long continuance of this disease, the brain 
becomes permanently diseased, and the intellect more or less impaired, 
in many cases approximating idiocy ; and, when this is not the case, in- 
sanity in some form is apt to be the result, numerous cases of which 
have fallen under my observation during the past few years. And in 
persons insane from spermatorrhoea, paralysis is very apt to occur, pro- 
bably in consequence of a softening of the brain, with a cephalic ten- 
dency, which so generally exists in such cases. 

Masturbation, as practiced by young children and females, is liable 
to produce the same train of symptoms as we have already seen, which 
occur in the male from spermatorrhoea, though in these cases there is no 
discharge; the irritability of the genital organs being reflected to the 
cerebro-spinal system, and deranging the ganglionic nerves, produces 
the same constitutional symptoms, though perhaps in a less degree. 

Thus we have, according to my observation, the main symptoms of 
spermatorrhoea, a disease which furnishes more dyspeptics, hypochon- 
driacs, lunatics, and idiots, perhaps, than any other affection ; and which 
causes a fearful proportion of the mortality which occurs in the young 
of both sexes. 

Causes. — Spermatorrhoea may occur from various causes, which tend 
to render the genital organs morbidly irritable ; such as ascarides in the 
rectum ; cutaneous eruptions on the external genital parts, or about the 
anus ; stricture of the urethra ; hemorrhoids ; fissure of the anus ; 
spinal irritation, and constipation of the bowels. 

But masturbation, onanism, and excessive sexual indulgences, are by 
far the most frequent causes of this affection ; and of the two, I believe, 
from careful inquiry, that masturbation is the most frequent cause. But 
in those who have practiced masturbation, whether male or female, and 
thus rendered the genital organs morbidly irritable, only a moderate 
degree of sexual excess is sufficient to develop the disease, with all its 
fearful consequences. 

Fathology. — The pathology of spermatorrhoea is very plain, when we 
remember the peculiar structure of the genital organs, and the strong 
sympathy existing between them and the cerebro-spinal system. 



SPERMATORRHEA. 661 

At first masturbation irritates the genital organs, in consequence of 
which erections take place, from a very slight exciting cause, attended 
often with a secretion and discharge of semen, but in no very great 
quantity at first. But as the habit and morbid discharge continue, the 
system becomes prostrated, nervous and irritable ; an irritation is set 
up in the spinal marrow, at the origin of the spermatic nerves, near the 
junction of the dorsal ^and lumbar portions of the spine, attended with 
more or less tenderness and pain. 

The brain finally becomes irritable, and in many cases softened ; suf- 
ficient nervous energy or influence not being generated to enable the 
different organs of the body to perform their functions ; and, as a con- 
sequence, the stomach, liver, and alimentary canal become deranged ; 
dyspepsia, constipation, &c. being the result. 

The hepatic derangement, together with the constipation of the bowels, 
produces in many cases hemorrhoids, fissures, or other local irritation, in 
the lower part of the rectum ; which, being in the immediate vicinity of 
the genital organs, greatly increase their irritation and the disease. 

Now the draft upon the blood, caused by the seminal discharge ; and 
the impaired nutrition, in consequence of the indigestion, greatly reduces 
the blood ; thus tending to soften and depress still more the brain, and 
to irritate the nervous system. The brain fails to afford the heart suffi- 
cient vital force, through the ganglionic nerves, to enable it to carry on 
the circulation in the extremities. As a consequence of this, the hands 
and feet become cold ; the brain becomes congested ; the patient, before 
hypochondriacal, becomes sullen, stupid, and often insane; and the heart, 
struggling to carry on the circulation, palpitates tumultously, and the 
patient is restless and irritable, or stupid and insensible, according to 
the degree of the cephalic congestion. And finally, insanity, in some 
form, with or without epilepsy, paralysis, or apoplexy, is very apt to be 
the result. 

In females, though there is no wasting discharge, masturbation or 
venereal excesses produces an irritable, congested, and inflamed condi- 
tion of the genital organs, and a sympathetic irritability of the cerebro- 
spinal system, thus deranging the generation and distribution of the 
nervous influence to the various organs, and materially interrupting 
their functions, developing, the same train of symptoms which occur in 
the male from similar causes. 

Such I believe is the true pathology of this disease, many cases of 
which have fallen under my observation and care during the past twenty 
years, both male and female. 

Diagnosis. — The diagnosis in males may readily be arrived at, if the 
patient will own the facts, and divulge the amount and frequency of the 
seminal discharge. 

But in many cases from masturbation or sexual excesses in the male 
or female, the facts will be stoutly denied, in which case the diagnosis 
is to be made from the symptoms which are developed. 

If then the patient, whether male or female, young or in middle life, 
married or unmarried, exhibits the symptoms which I have described, it 
is morally certain, that either masturbation, onanism, excessive sexual 
indulgence, or some other influence, which produces a similar condition 



662 DISEASES OF THE GENITAL ORGANS. 

of the genital organs is the cause, and in males generally, that there is 
a spermatorrhoea, either diurnal or nocturnal. 

The cold extremities, pale face, sunken eyes, downward look, palpi- 
tation, cephalic congestion, indigestion, irritability, hypochondria, and 
idiotic expression of countenance, together with the tendency to insanity, 
epilepsy, apoplexy, &c, are the symptoms to be relied on, in forming a 
diagnosis in such cases. 

Prognosis. — The prognosis in recent cases provided the cause can be 
removed, is generally favorable. In protracted cases, however, in which 
the brain has become softened, or in any way very materially involved, 
the prognosis is always unfavorable. 

Treatment. — The first indication in the treatment of this disease is to 
stop or correct the imprudence which has produced it. If the cause be 
masturbation, as is generally the case, its fearful consequences should 
be pointed out, and the continuance of the habit strictly forbidden, 
whether the patient be male or female. 

If excessive sexual indulgence be the cause, that habit should be cor- 
rected or brought within reasonable bounds, as entire continence in the 
married, might lead to, or increase diurnal or nocturnal discharges. It 
may be a matter of doubt, how often sexual indulgence might be salu- 
tary in such cases, but I believe it should not be allowed oftner than 
once in three or four weeks in the married, while in the unmarried it 
should of course be strictly prohibited. 

If onanism be the cause, as it very often is, that most ruinous habit 
should be prohibited, as it not only leads to great irritability of the 
male genital organs, but it also evidently produces an irritable condition 
of the female upon whom it is practiced, similar to that produced by 
masturbation, or perhaps worse. 

The patient should be directed to take a plain nourishing diet, that 
of milk and bread made from unbolted flour, with an allowance of meat, 
and cold water for drink, will generally do best. The food too should 
be well masticated and taken with strict regularity. 

The patient should be made to wash the surface of the body, once or 
twice per week, with moderately cool water, containing a little salt ; 
taking care to rub the skin dry with a towel. Flannel should be worn 
next the skin, to promote warmth and favor perspiration, and the 
patient should be directed to lay on the side in bed, at all times, and 
to be comfortably, but not too warmly covered. 

If there i& piles, fissure of the anus, or soreness in the lower part of the 
rectum, from the long continued constipation, or if the bowels continue 
constipated, or there is ascarides in the rectum, a free injection of cool 
water should be used each morning, and a movement secured, in prefer- 
ence to any other hour of the day. As an application to the piles the 
ointment already suggested, in the article, Hemorrhoids, in the eighth 
chapter of this work, may be applied ; or an ointment made by mixing 
together the extract of stramonium, oxide of zinc, and tannin, of each two 
drachms, and then adding and mixing, intimately, two ounces of simple 
cerate, may do equally well in such cases. Of either of these oint- 
ments a little may be applied, with the end of the finger, morning and 
evening, while the pain and soreness continue. 



GONORRH(EA. 663 

If there is a fissure of the anus, or an eruption upon the surface 
about the anus, an ointment, made by mixing two drachms each of the 
oxide of zinc and tannin, with an ounce of lard, applied morning and 
evening, will generally do best. Or, if the eruption or roughness ex- 
tends to the external genital parts, as it is apt to in females, a solution 
of borax, two drachms to eight ounces of water, may be applied, morn- 
ing and evening, instead of the ointment of oxide of zinc, as it is more 
cleanly, and will generally subdue the irritation. 

Dry cups should be applied occasionally to the back of the neck, and 
also along the junction of the dorsal and lumbar regions of the spine, 
at the origin of the spermatic nerves. 

As a tonic, for the cerebro-spinal and nervous system, the muriate of 
strychnia, in ^V of a grain doses, will generally do best. It is most 
conveniently administered by dissolving a grain of the muriate in eight 
ounces of water, of which a teaspoonful may be given, three times per 
day, before each meal ; and continued as long as it may be required. 
This will generally regulate the bowels, improve the digestion, etc., by 
its tonic effect upon the nervous system. 

As a tonic for the blood, some preparation of iron should be given, 
and continued for a long time. If only the tonic effect is wanted, two 
or three grains of the carbonate, or ammoniated citrate, may be given, 
three times per day, after each meal. If however an alterative is indi- 
cated, ten drops of the syrup of the iodide should be given instead. 
Or, if the bladder has become irritable, as is often the case, ten drops 
of the tincture of the chloride of iron will generally do best. 

This course of treatment commenced in season, and judiciously ap- 
plied, so as to fulfill the indications in each particular case, will gene- 
rally prove successful. In case of failure however, the prostrate gland 
may be cauterized with the nitrate of silver, by means of the instrument 
of M. Lallemand. 



SECTION II.— GONORRHOEA. 

By gonorrhoea, I mean here, that peculiar contagious disease, consist- 
ing of a specific inSammation, attended with a mucous or purulent dis- 
charge ; having its seat generally in the mucous membrane, of the male 
or female genital organs. 

The urethra of the male, and the vagina of the female, are the most 
common seats of this affection. It may occur, however, in the inner 
surface of the prepuce, or on the glans penis of the male, or in the 
vulva, or uterus in females. Or the disease may be produced in any 
part of the body, if the matter of gonorrhoea be brought in contact with 
a mucous surface. 

In relation to the identity of gonorrhoea and syphilis, there is a diffi- 
culty in arriving at a definite conclusion, as both affections frequently 
exist in the same individual; but I incline to the opinion, that the 
diseases are distinct. 

The period between the exposure and the appearance of the disease, 
varies from a few hours, to several weeks ; but four or five days, is about 
the usual time, in most cases. 



664 DISEASES OF THE GENITAL ORGANS. 

There is sometimes a purulent or mucous discharge from the male or 
female genital organs, not the result of the venereal poison, which re- 
sembles it, except that it is not contagious, and that the discharge is 
attended with a disposition to resolution, while in gonorrhoea, the matter 
secreted being a virus, tends to keep up, instead of terminating the in- 
flammation. Gonorrhoea then, as it occurs in the male or female, is 
attended with a peculiar train of symptoms, which we will now proceed 
to consider. 

Symptoms. — Generally after an indefinite period, varying from a few 
hours, to five or six days after exposure, there is felt an itching at the 
orifice of the urethra, and sometimes over the whole glans ; a little full- 
ness appearing at the lip of the urethra. Soon this itching is changed 
to a pain, especially at the time of voiding urine, and with the symp- 
toms of inflammation of the mucous membrane which are developed, the 
discharge appears. In some cases, however, there is no pain, till after 
the appearance of the discharge, and occasionally a case occurs, in which 
there is little or no pain, even though the discharge be very considerable. 

At this stage, there is a fullness of the penis, especially of the glans, 
the organ being to appearance, in a state of half erection, and the 
glans having a degree of transparency near the orifice of the urethra, 
the surface being full and red. In consequence of the fullness of the 
penis, and swelling of the urethra from inflammation, the stream of 
urine is smaller than usual, and is generally scattered and broken, as it 
leaves the passage. And if the distension of the urethral vessels be 
considerable, there is sometimes a hemorrhage from the urethra; but 
this is not generally the case. The glands along the under side of the 
penis sometimes enlarge, and occasionally they inflame and suppurate. 
A soreness is also sometimes felt along the under side of the penis, owing 
to a high state of inflammation of the urethra. 

In consequence of the irritation of the penis, erections of a very 
painful character are liable to occur in gonorrhoea, especially in cases 
in which the inflammation runs high and is attended with considerable 
pain. 

The discharge in gonorrhoea appears like pus, and is probably the 
result of inflammation, changing the slimy discharge from the glands of 
the urethra, as well as the natural exhaling fluid of the canal to this 
character. The matter is sometimes lightish or greenish, but generally 
of a yellowish color ; but if it continues and becomes a gleet, it is of a 
watery character, being sometimes almost transparent. 

The inflammation in gonorrhoea generally extends back along the 
urethra for half its length, and in some cases further. And when the 
inflammation extends deep to the reticular membrane, becoming adhe- 
sive and uniting together the cells of the corpus spongiosum urethra, it 
destroys in some cases its power of distension, so that a curvature takes 
place at the time of erection, which has been called a chordee. 

An occasional attendant of gonorrhoea is a swelling of one or both 
testicles. It may occur at any stage of a gonorrhoea, but it more fre- 
quently happens from a sudden suppression of the discharge from some 
cause. As the inflammation of the testile becomes fully established, it 
is attended with severe pain, both in the gland and in the back at the 



GONORRHOEA. 665 



origin of the spermatic nerves. Sympathetic vomiting is apt to occur, 
and also more or less spasmodic pains in the bowels. Orchitis is also 
attended with more or less febrile excitement. 

Gonorrhoea in women is not attended generally with a very high 
degree of inflammation or much pain, if only the vagina is involved. 
But if the womb, vulva, or urethra becomes involved, there is generally 
a good deal of pain, especially in walking, passing water, &c. The 
discharge does not differ very materially in appearance from the matter 
of leucorrhoea, so that the evidence of gonorrhoea in women depends 
upon the fact of their having been exposed, or of their having commu- 
nicated the disease to some one, all other symptoms being sometimes 
deceptive. 

In some cases of gonorrhoea, in both males and females, the glands of 
the groin become enlarged and indurated, and various constitutional 
symptoms arise, such as slight irritation of the fauces, a papular erup- 
tion of the skin and slight swelling of the joints, with more or less 
febrile excitement. 

Such are the ordinary symptoms of gonorrhoea as it occurs both in 
the male and female, liable of course to variations, like all other affec- 
tions. 

Treatment. — If the patient be seen after the exposure, and before the 
disease makes its appearance, he should be directed to wash the parts 
thoroughly with soap and water, and then with a saturated solution of 
alum and water, and if there is slight uneasiness, a little of the solution 
may be injected into the urethra. Or if the patient be a female, into 
the vagina. This washing with the alum solution, and injection, if ne- 
cessary, may be repeated morning and evening, for two or three days, 
and may, in some cases, enable the patient to evade the physical penalty 
of broken law, but not always. 

If, however, the disease is fully established, measures should be taken 
at once to subdue the inflammation, and then to arrest the discharge. 

The patient should be directed to be quiet, and if the attack is severe, 
to keep in bed. A cathartic of the sulphate of magnesia should be 
administered, and then the bowels kept moderately loose, by teaspoon- 
ful doses repeated each morning, if necessary. Tartar emetic in one- 
fourth of a grain doses should be given every three hours, till the in- 
flammation in a measure subsides, and if there is much pain in the back, 
cups may be applied, and a little blood taken. 

After thus subduing the severity of the inflammation, in violent cases, 
and immediately after the operation of the first cathartic, in mild cases 
attended with little inflammation, half a drachm of the balsam of copaiva 
may be given, from three to five times per day, in the form of emulsion, 
with sugar, gum arabic and water. It may be conveniently prepared 
by mixing together in a mortar, an ounce each of pulverized gum 
arabic, sugar, and water, or perhaps a little more water, and then 
adding very slowly while stirring, an ounce of the balsam of copaiva. 
When the balsam is thus all intimately mixed, half an ounce of the com- 
pound spirit of lavender may be added, and then sufficient water gradu- 
ally stirred in, to make eight ounces of the mixture. Of this a table 
spoonful may be given after each meal, and if it does not loosen the 



666 DISEASES OF THE GENITAL ORGANS. 

bowels too much, early in the morning and at evening. In preparing 
the mixture for cases in "which there is little pain, half the quantity of 
gum arabic and sugar may be sufficient, or even less than that. But in 
violent cases, in which there is pain, heat, and scalding on passing urine, 
I believe that a liberal allowance of the gum constitutes a valuable in- 
gredient in the mixture. 

In case the discharge continues, after four or five days, the emulsion 
may be prepared in the same way, with the addition of an ounce of the 
tincture or fluid extract of cubebs, to each eight ounces, and this should 
be continued with the use, if necessary, of injections, till a cure is 
effected. If injections become necessary, as they may in some cases, 
half a drachm of the sulphate of zinc may be dissolved in eight ounces 
of rain water, and a small quantity of this should be thrown into the 
urethra, with a small syringe, four times per day. 

If, however, a gleet supervenes, or follows the gonorrhoea, a saturated 
solution of alum in rain water may be used, instead of the zinc, and if 
this fail, a solution of tannin, two drachms to eight ounces of water may 
be resorted to, and continued till the gleet is arrested. 

The treatment for females with gonorrhoea, should be the same as 
for males, only as an injection, a solution of alum, two drachms to the 
pint of water, will generally do best, at first. But if the disease becomes 
chronic, tannin of the same strength should be used, and continued till 
the discharge is arrested. 

When the testicles become swelled in males, cups should be applied 
to the back, at the seat of the pain, and a few ounces of blood taken ; 
a saline cathartic should be given, and four grains each of James's and 
Dover's powder administered, every four or six hours, till the febrile 
excitement subsides. As an application to the testicles in such cases, 
a solution of the muriate of ammonia, of the strength of two drachms to 
eight ounces of vinegar, with the addition of two drachms of laudanum, 
will generally do best at first. Later, however, a solution of the iodide 
of potassium, two drachms to eight ounces of water, may be applied by 
means of a cloth saturated with it, and over this a poultice of hops, wet 
in warm vinegar or water should be kept applied till the swelling subsides. 

Finally, if constitutional symptoms follow gonorrhoea, such as swel- 
ling of the joints, sore throat, &c, a blue pill may be given at evening 
for a few days, followed by a teaspoonful of the sulphate of magnesia in 
the morning, and then the iodide of potassium should be given in five 
grain doses, three times per day, and continued till a cure is effected. 

SECTION III.— SYPHILIS. 

By syphilis is here meant that peculiar infectious disease usually 
affecting primarily the male or female genital organs, the first devel- 
opment of which is a small pimple, sore, or chancre, but if neglected, 
producing various constitutional symptoms, involving the glands, throat, 
skin, bones, &c. 

The primary sore or chancre may occur on the internal surface of the 
prepuce, the glans, the external surface of the prepuce, skin of the 
penis, scrotum, or thighs of men, and in females, on the internal or 






SYPHILIS. 667 

external surface of the labia pudendi, on the clitoris, the nymphea, in 
the vagina, or on the thighs. 

This sore or chancre may make its appearance at an indefinite period 
varying from a few days to several weeks, after an impure connection, 
and is at first a strictly local disease. This mere pimple or chancre, if 
left to itself, leads on to a train of general or constitutional symptoms, 
which we will now proceed to consider, leaving the diagnostic charac- 
ters of the chancres for consideration when we come to the diagnosis. 

Symptoms. — The primary sore of syphilis, a mere pimple at first, if 
allowed to pass on, furnishes a virus, which being taken up by the ab- 
sorbent lymphatic vessels of the part, and carried into the system, event- 
ually poisons, deranges, or contaminates all the fluids, and solid tissues 
of the body. As this virus passes through the lymphatic glands of the 
groin, they frequently become inflamed, enlarged, and suppurate, con- 
stituting a bubo in one or both groins. Now this state of the disease 
during which the poison is being carried into the system may be called 
the consecutive stage, and occupies the time from the fifth or sixth day 
to the second or third week after the first appearance of the pimple, 
sore or chancre. 

After the venereal virus has been carried into the blood or general 
system from a chancre or syphilitic bubo, certain constitutional symp- 
toms make their appearance, and this constitutes the secondary stages 
of the disease. The secondary symptoms usually make their appear- 
ance by the fifth or sixth week after the chancre, and from one to three 
weeks after the appearance of the bubo. 

These secondary symptoms usually make their appearance first in 
the throat, by a slight soreness, and then on the skin by a peculiar scaly 
or other eruption, which may affect any part of the surface, but espe- 
cially the forehead, neck, breast, forearms, legs, and anterior part of 
the abdomen. And usually as the scales fall, after these sores, they 
leave a peculiar copper colored base or scar. 

If now the disease be not arrested, the periosteum, fascia, ligaments, 
and bones become affected, and this constitutes the tertiary stage of 
syphilis. 

The bones most frequently affected are the cranium, sternum, clavicle, 
and those generally nearest the surface, the nodes which are formed 
being a simple enlargement of the bone, not attended with discoloration 
at first, but becoming painful after it has continued for a time. 

Such then, it should be remembered, are the ordinary symptoms of 
syphilis, during its primary consecutive, secondary, and tertiary stages, 
the chancre being the symptom of the primary stages, the bubo when 
it appears of the consecutive, the sore throat and cutaneous eruption of 
the secondary, and the affection of the bones, with nodes, &c, of the 
tertiary stage of the disease. And it should still further be remembered 
that the disease is primary and local for the first five or six days, con- 
secutive from the fifth or sixth day, to the second or third week, second- 
ary for several weeks, or perhaps months, and tertiary from the first 
appearance of the nodes, and perhaps earlier, during the continuance 
of the disease. Thus we see that one stage supervenes upon another 
till the whole of the fluids, and solid tissues of the body become contami- 



668 DISEASES OE THE GENITAL ORGANS. 

nated, and unless the disease be arrested, disorganization of the various 
tissues takes place, and the patient finally becomes a wreck of pollution, 
till death at last pays the physical penalty of broken law. 

Diagnosis. — The diagnosis of syphilis, and especially of chancre, is 
attended sometimes with considerable difficulty, as other sores, not 
syphilitic, are liable to occur on the genital organs, and also as the 
chancre is liable, from peculiar conditions of the system, to marked 
variations. Generally, however, if a sore makes its appearance on the 
genital organs, within a few days or even weeks after exposure, and as- 
sumes an appearance answering to the following descriptions, it may be 
regarded as chancre. 

The indurated chancre is preceded by an itching, a small pimple 
first appearing, which soon contains matter, and then turns into a regu- 
lar ulcer, the base of which is hard, and its edges regular. The thicken- 
ing of the tissues about it does not extend far, being rather circum- 
scribed. The edges of the ulcer are surrounded by a narrow line of in- 
flammation, and the bottom of the sore is covered with a gray or yellow- 
ish matter which adheres, and differs from common pus. Gradually the 
edges of the sore become rounded off, the areola disappears, and if the 
sore heals it leaves a hardened cicatrix which is liable to ulcerate again. 

The simple chancre which is more common than the indurated, resem- 
bles it very much, only the base of the ulcer is free from hardness, and 
it is not attended with any very considerable signs of irritation or in- 
flammation. 

The irritable chancre differs in being red, painful, and irregular in 
appearance, and very much disposed to spread, if irritating applications 
be resorted to. 

The inflamed chancre is a modification of the simple, caused by the 
supervention of inflammation, frequently from excesses on the part of 
the patient, in consequence of which it becomes painful, red and swelled, 
and loses its regular appearance. The edges of the ulcer in these cases 
are often removed by dark sloughs, and the secretion becomes of an irri- 
tating or acrid character. 

The sloughing chancre occurs in persons of broken down constitutions, 
caused by excesses of various kinds, in consequence of which the ulcer 
and surrounding parts are destroyed by sloughs or gangrene, destroying 
in some cases a large part of the genital organs, in either sex. 

If then a sore be found upon the genital organs, or in their vicinity, 
presenting either of the preceding characteristics, and the patient has 
been exposed, the disease may be regarded as syphilitic, the variations 
in the appearance depending probably in the main upon the habits, con- 
stitution of the patient, &c. 

If, however, the patient is not seen till the consecutive stage, there 
will generally have been the supervention of other symptoms, and often 
that of bubo. And still later, during the secondary stage, there is the 
supervention of sore throat, scally eruptions, &c. Finally in the tertiary 
stage, when in addition to all the preceding diagnostic symptoms, nodes, 
ulceration of the bones, and other tissues, and other like S3miptoms shall 
have supervened, the diagnosis is rendered clear and positive. 

Thus may syphilis, in all its stages and variations, generally be known, 
without the necessitv of a reasonable doubt. 



SYPHILIS. 6G9 

Treatment. — If a patient apply any time within six days after the 
first appearance of a chancre, it should be cauterized by passing over 
it lightly a stick of lunar caustic. A piece of dry lint should then be 
applied over the sore, and secured by a bandage. After the first scab 
formed by the caustic falls off, it may be cauterized again, and this 
should be repeated, if necessary, till the -whole surface of the sore shows 
a tendency to heal. 

As soon as the reparative process commences, the sore may be dressed 
with the ointment of oxide of zinc, or if it is disposed to discharge rather 
freely, the sore may be washed four times per day with a solution of 
eight grains each of tannin and sulphate of zinc in four ounces of rain 
water, and a small bit of cotton or lint, wet in the solution, may be kept 
constantly applied. This treatment should be continued till the chancre 
heals. 

This may be all the treatment required if the chancre has not con- 
tinued more than five or six days when the treatment was commenced. 
If, however, the disease be not arrested by these measures, and the con- 
secutive stage approaches, as well as in all cases that are neglected till 
the disease has passad on to this stage, with perhaps inflammation of the 
lymphatic glands in the groin, constitutional treatment should be resorted 
to at once. 

Five grains of blue mass may be given morning and evening, and con- 
tinued till a mercurial taste is perceived in the mouth, or slight ptya- 
lism is produced, when it should be discontinued, and five grains of the 
iodide of potassium given three times per day instead, and continued 
till a cure is effected. 

If a bubo appears, attended with febrile excitement, a full dose of the 
sulphate of magnesia should be administered, and a cold solution of the 
muriate of ammonia in vinegar, two drachms to eight ounces, kept 
applied to the inflamed gland. If, however, the bubo increases, a blister 
may be applied, and the raw surface dressed, as it begins to heal, with 
mercurial ointment, or if the mercurial is not tolerated, the compound 
iodine ointment may be applied instead. 

With the blue pill, followed by the iodide of potassium, the blisters, 
and mercurial or iodine ointment to the buboes, and the oxide of zinc, 
ointment, or solution of tannin and sulphate of zinc to the chancre, the 
disease may be arrested in most cases, and the secondary and tertiary 
symptoms not occur. 

In cases, however, that have been neglected till secondary symptoms 
appear, the blue mass should be given morning and evening, as already 
suggested, till a slight ptyalism is produced, and then thefiodide of potas- 
sium should be substituted, and continued till a cure is effected, adminis- 
tered in the fluid extract, syrup, or compound decoction of sarsaparilla. 

In cases of syphilis that have passed on to the tertiary stage, with 
nodes, nocturnal pains, &c, the iodide of potassium may be given in 
ten grain doses with the sarsaparilla, with the addition of full doses of 
the syrup of the iodide of iron, if necessary. 

In all cases of syphilis in which a mercurial is contra-indicated from 
any cause, ten drops of the fluid extract of stillingia should be given 
three times per day instead, with the iodide of potassium and sarsapa- 
rilla, and continued till a cure is effected. 



670 DISEASES OF THE GENITAL ORGANS. 



SECTION IV.— METROPERITONITIS. 

By metroperitonitis, from ^rpa "the uterus," and " peritonitis,"- Jt 
mean here inflammation of the uterus and peritoneum, liable to occur at 
any time, but generally in the puerperal state. 

The uterus or womb is situated, it will be remembered, near the middle 
of the cavity of the pelvis, between the bladder and rectum, above the 
vagina, and below the small intestines. 

It consists of a body, neck, and cavity. The body is about two inches 
long, terminating in the neck inferiorly, which is smaller than the womb, 
and about ten or twelve lines in length. The lower extremity of the 
neck projects into the vagina, and is called the os tincse. 

The cavity of the womb is small, occupying the body and neck, that 
of the neck consisting of a mere canal, commencing in the os tincse by 
a transverse opening, and being continuous above with the cavity of 
the womb. This cavity in turn is triangular, and at its superior angles, 
on each side, is continuous with the opening of the Fallopian tubes. 

The uterus is composed of an outer serous or peritoneal coat, a 
mucous or internal lining membrane, and a middle parenchyma, of a 
muscular character, together with its arteries, veins, and nerves. 

The outer or peritoneal coat of the womb, consists of a duplicature 
of the peritoneum, which being extended across, and connected with 
the sides of the pelvis, constitute the brad ligaments of the uterus, 
enclosing the Fallopian tubes, with their fimbriated extremities, as well 
as the ovaries, connected by their ligaments with the uterus, and also 
with the fimbriated aperture of the Fallopian tubes. 

The internal mucous membrane of the womb is continuous with that of 
the vagina, through the canal of the neck, and is firmly adherent to the tis- 
sue of the organ, lining its whole cavity, and extending also into the cavity 
of the Fallopian tubes, which are lined to their fimbriated extremities. 

The middle muscular coat of the womb, constituting its parenchyma, 
which gives thickness and bulk to the organ, is of a whitish color, of a 
dense elastic structure, and consists of an external and internal layer 
of fibres, mingled with arteries, veins, and nerves. 

The arteries of the womb consist of the uterine, from the internal 
iliac, and the spermatic, from the aorta ; its veins terminate on each 
side of the organ, in the uterine plexuses ; and its nerves are derived 
from the hypogastric, spermatic, and sacral plexuses. It is also well to 
remember in this connection, that the womb has two round ligaments, 
which serve to retain the organ in its place, extending from its upper 
angles, along the spermatic canal, to the labia major a, in which they 
are lost. 

Now, when we take into account the position and structure of the 
womb, it is not strange that it should become inflamed, especially in 
the puerperal state, when all its vessels have been very much enlarged 
and distended. Nor is it strange that an inflammation of the uterus, 
occurring in the puerperal or any other state, should extend to its peri- 
toneal covering, and from that to other parts of the peritoneum, and 
thus produce a rapidly fatal metro-peritonitis. 

It is this inflammation of the womb, extending to the peritoneum, 



METROPERITONITIS. 671 

and occurring most frequently in the puerperal state, a few days after 
parturition, which now demands our attention ; the symptoms of which 
we will now proceed to consider. 

Symptoms. — There is usually more or less pain experienced in the 
uterus, attended with some tenderness, at the very commencement of 
the inflammation. But in many cases there is a chill, succeeded by 
fever, before any serious pain is experienced in the uterus. There is 
however in all cases, sooner or later in the disease, a fixed, continuous, 
and lancinating or dull and aching pain in the pelvis, which is greatly 
increased by pressure or motion, and accompanied also with a sense of 
weight in the perinceum. 

"The urine is passed with difficulty, especially if the lower and anterior 
portion of the womb is involved in the inflammation. If the inflamma- 
tion involves the posterior part of the organ, the pain is severe in the 
sacral region, and the patient experiences considerable tenesmus of a 
more or less distressing character. Sometimes the pain is severe in the 
iliac regions, and extends to the hips and down the thighs, especially is 
this the case if the lateral portions of the womb are involved, more 
particularly in the inflammation. But more generally, however, in 
.severe cases there is a combination of nearly all these symptoms, indi- 
cating that the whole uterus is involved in the disease. 

In the early stage of the inflammation, if it is confined mainly to the 
uterus, very little or no swelling of the abdomen occurs ; but on examin- 
ing the pubic region with the hands, the womb is found considerably 
enlarged being firm and tender to the touch. But if, as generally hap- 
pens in such cases, the inflammation extends from the womb to the 
peritoneum, there is a good deal of tenderness of the abdomen and 
considerable tumefaction. 

In puerperal cases of this disease, there is generally an entire sup- 
pression of the lochia, as well as cessation of the secretion of milk. 
As the disease progresses, the pulse becomes frequent ; there is great 
prostration of strength ; frequent muttering delirium ; constant recum- 
brance on the back with the knees drawn up and the shoulders raised ; 
a dry, coated, brown tongue ; and frequently towards the termination a 
diarrhoea occurs. 

In the majority of cases the system sympathizes strongly with the 
inflamed organ, even before the inflammation has extended to the peri- 
toneum. In most cases there is nausea with occasional vomiting. The 
pulse is either full, strong and hard, or contracted, small and frequent. 
There is also usually severe headache, and towards evening more or less 
delirium occurs. 

The course of this disease is generally rapid, and if the inflammation 
does not tend to resolution in four or five days, it will generally termi- 
nate in suppuration or gangrene. 

When the inflammation tends to a favorable termination, the pain, 
tenderness and swelling of the womb abate, and the abdominal disten- 
sion subsides. The pulse becomes slower, soft and open ; the skin 
moist ; the tongue clean and humid ; the lochia flows more freely ; and 
the urine becomes more free and natural in its appearance. 

The occurrence of suppuration in the substance of the womb is always 



672 DISEASES OF THE GENITAL ORGANS. 

attended with considerable danger. For if the abscess bursts into the 
cavity of the peritoneum, or passes between the peritoneum and the ex- 
ternal surface of the womb, into the cellular tissue in the lower part of 
the pelvis, there will generally be a fatal termination. If, however, the 
matter finds its way into the cavity of the uterus, it may then be dis- 
charged through the vagina and a favorable termination may be the 
result. 

The occurrence of suppuration may be suspected, when in an obsti- 
nate or severe case, which has passed on five or six days — the pain gra- 
dually subsides, being followed by a sense of weight in the affected part. 
The pulse, too, becomes more frequent, slight chills occur, the distribu- 
tion of heat becomes irregular, cool sweats appear, the lochia becomes 
fetid, there is prostration of muscular power, and generally the tongue 
becomes red, and a livid flush may appear on one or both cheeks. 

A termination in gangrene is not an unfrequent event, if, as gene- 
rally happens, the peritoneum is extensively implicated in the inflam 
mation. 

On the supervention of gangrene, there is a rapid cessation of pain, 
great muscular prostration, vision becomes impaired, the countenance 
becomes cadaverous, a clammy sweat breaks out, the extremities become 
cold, the pulse becomes small, weak, and rapid, and finally death puts 
an end to the sufferings of the patient. 

In cases of this disease, in which the peritoneum becomes rapidly and 
extensively involved in the inflammation, unless it be speedily subdued 
by prompt and early measures, a collapse of the vital energies may 
supervene in forty- eight hours, or even sooner, in some cases. 

Such, I believe, are the ordinary symptoms of metroperitonitis, liable 
to variations, as is the case with all diseases. Cases occurring out of the 
puerperal state are quite rare, and, when they do occur, do not develop 
the symptoms incident to the puerperal state, of course. 

Anatomical Characters. — The parenchyma of the womb is frequently 
found containing more or less matter in different parts, or the abscesses 
have burst into the uterine cavity, or opening externally, the matter has 
passed between the outer surface of the womb and its peritoneal coat, 
into the lower part of the pelvis, or having burst through the peritoneal 
coat, it is found in the peritoneal sac. 

The peritoneal coat of the uterus exhibits signs of recent inflamma- 
tion, as well as the parts immediately surrounding that organ, and not 
unfrequently the whole peritoneum shows signs of recent inflammation. 
It may be found red and thickened, and the abdominal viscera are often 
found adhering to one another by effused lymph, or there may be found 
a turbid serous fluid, containing shreds of albumen, pus, or blood, in the 
peritoneal sac. 

The omentum is found of a deep red color, is apt to be highly vascu- 
lar, and is not unfrequently adherent to the fundus of the uterus, by 
means of effused lymph. Finally, in some cases, the uterus and its 
appendages present a gangrenous appearance, as well as the peritoneum, 
not only that portion which lines the parietes of the abdomen, but also 
that which is reflected over the intestines, forming their outer or peri- 
toneal coat. 



METROPERITONITIS. 678 

Causes. — Metroperitonitis, as it occurs out of the puerperal state, 
may be caused by injuries, exposure to cold, when the body is heated, &c, 
in the same manner that these influences produce inflammation of other 
parts. 

Various causes may operate to produce this disease in the puerperal 
state. Immediately after parturition, the womb undergoes various im- 
portant changes, which may have a bearing on the development of this 
disease, if proper care and prudence is not exercised. Its internal lining 
membrane has been irritated by the detachment of the placenta, and 
the mouths of the extreme uterine vessels, doubtless remain for a little 
time imperfectly closed, which may predispose the organ to take on in- 
flammation. 

The womb is liable too, during contraction in labor, to slight over 
distension of its structure, by which its arteries, veins, and lymphatics 
become lacerated, or very much distended, and their natural contractile 
powers impaired in a greater or less degree, for the time, in consequence 
of which, they remain in a passively congested condition, predisposing the 
organ to congestion or passive inflammation. There is also the liability 
of direct injury of the organ during labor, by the hand in turning the 
child, or by the introduction of instruments. 

Now after parturition, the womb, from having been in a condition of 
active distension, is in a weak, debilitated, and relaxed state, and the 
pressure of the foetus having been removed, leaves its tissues more or 
less predisposed to congestion or passive inflammation. If now, with all 
these predisposing circumstances, the patient be imprudently allowed 
to assume the erect or sitting posture, within the first few days after 
confinement, the position will still further tend to increase the conges- 
tion of the uterine vessels, by impeding the return of venous blood along 
the inferior vena cava, and portal veins. 

In this way a passive congestion of the organ may increase, till the 
womb becomes sensibly enlarged, and slightly tender to the touch. This 
liability to congestion is also greatly increased by the faintness or pros- 
tration which is liable to occur, from the patient assuming the erect or 
sitting posture, within the first few days after confinement. 

The blood, as in all other similar conditions of the system, does not 
pass freely to the extremities, in consequence of diminished action of the 
heart and arteries. And as the erect position lessens the flow of blood 
to the brain, and increases its flow to the uterus, a degree of passive 
congestion is produced in the arteries, veins, and capillaries of the womb, 
which so far irritates the organ, as to stop the lochial discharge from its 
inner or mucous surface. This retained lochial matter still further in- 
creases the already excessive irritation, and pain, swelling, and tenderness 
is the result. 

But the impression of this morbid condition is carried to the brain, 
through the sympathetic and cerebro-spinal nerves, and nausea, vomiting, 
and prostration of the powers of the system follow, during which the 
blood recedes from the extremities, and a violent chill follows. 

During this chill the congestion of the womb amounts to an enormous 
distension of its vessels and tissues, which sets up a passive inflamma- 
tion of its mucous, muscular, and serous tissues, attended with general 
43 



674 DISEASES OF THE GENITAL ORGANS. 

febrile excitement, nausea, vomiting, and very soon, great prostration of 
the powers of the system. 

Though there is in such a case, violent throbbing of the vessels of the 
womb, they are unable to relieve the congested and inflamed organ. 
And the inflammation being rendered still more putrid or malignant by 
the retained lochia, if it is not soon arrested, spreads rapidly to the ap- 
pendages of the womb, and also to the peritoneum, developing all the 
symptoms which occur in what has sometimes been called "puerperal 
fever," but which appears to be really a metroperitonitis. 

And finally, if the disease be not arrested, it terminates either in sup- 
puration, involving in a greater or less degree the different tissues of the 
womb, or in gangrene of the womb, its appendages, and more or less of 
the peritoneal sac. 

Such I believe are the causes or circumstances which lead to metro- 
peritonitis in the puerperal state. But it should be remembered, that 
in addition to the imprudent assumption of the erect or sitting posture, 
soon after confinement, that various other exciting causes may operate 
to develop the disease. Among these causes are sudden exposure to cold 
or dampness, large draughts of cold water, violent mental emotions, 
want of cleanliness, epidemic, and other kindred influences, all of which, 
I am satisfied, tend to develop the disease, in the manner already sug- 
gested. 

Now, while cases of puerperal metroperitonitis are generally of a pas- 
sive character, it should be remembered that exceptions occur occasion- 
ally in the puerperal state, and that in the disease, as it occurs out of 
the puerperal state, from wounds or other accidental causes, the inflam- 
mation is generally of a decidedly active character. 

Treatment. — The treatment of metro-peritonitis out of the puerperal 
state, as well as of the occasional puerperal cases in which the inflamma- 
tion is of an active character, should be similar to that for inflammation 
of other vital or important parts, and should consist of general bleeding, 
cupping, a mercurial cathartic, sinapisms, fomentations, and opium or 
Dover's powder, with calomel in alterative doses, and in some cases 
blisters may be required. 

The treatment of puerperal metroperitonitis, being, as I believe it 
generally is, of a passive character, requires a sound discretion and the 
exercise of good common sense. 

In the first place, by carefully avoiding any injury of the womb in 
examinations which sometimes become necessary during labor, by ap- 
plying a bandage moderately tight about the abdomen after delivery, 
and by enjoining and enforcing the recumbent or horizontal position for 
the first ten days at least, and then only occasionally allowing the sit- 
ting posture in bed for another week, I believe that puerperal metro- 
peritonitis may generally be avoided, if prudence is exercised in other 
respects. 

But if from any cause the disease makes its appearance, measures 
should immediately be taken to equalize the circulation, to counteract 
local and general irritation, and to keep up the sinking powers of the 
system. 

Cups should be applied over the sacrum, and to the hypogastrium, 



CHRONIC METRITIS. 675 

and from two to six ounces of blood taken. The spine should be 
thoroughly rubbed with a strong infusion of capsicum in vinegar, with 
a view of equalizing the circulation, which it will very generally materi- 
ally assist in doing. A full dose of calomel and castor oil should be ad- 
ministered, and its operation secured by repeating the oil if necessary. 

After the operation of a cathartic, there is generally considerable pros- 
tration, and though the local inflammation continues, it is generally of a 
passive character, and greatly aggravated by a debilitated condition of 
the system. To quiet pain and general irritability, keep up the sinking 
powers of the system, and produce a slight alterative effect, Dover's 
powder, quinine, and calomel should now be given. 

About two grains of calomel, three grains of quinine, and five grains 
of Dover's powder may be given every four hours, and continued till a 
slight impression is produced on the gums, or the inflammation yields, 
when the calomel should be omitted, and three grains of James's pow- 
der added to the quinine and Dover's and this should be continued every 
four or six hours, increasing the quinine if necessary, till the disease is 
arrested. 

After cupping, some benefit may frequently be obtained by a warm 
hop poultice, to the perinaeum or hypogastrium. The bowels should be 
kept gently loose by small doses of castor oil, and in some cases much 
benefit may be derived from sinapisms over the abdomen, and especially 
to the hypogastrium, in the early stages of the disease. Blisters too in 
some rare cases may be indicated. But generally I think they produce 
too much irritation for a patient in the puerperal state. 

The patient should be nourished by crust coffee one half milk, and 
some plain solid food should be allowed as soon as the stomach will bear 
it. 

In cases of this disease of a highly putrid or malignant character, in 
addition to the quinine, camphor, carbonate of ammonia, wine-whey, 
and even brandy may be required to sustain the sinking powers of the 
system. 

By thus keeping in mind the exact condition in each case of this dis- 
ease, and doing just that which is indicated, and nothing more, I believe 
that the disease, though always attended with danger, may generally be 
arrested, if attended to in season, unless there is some special malignancy 
as occurs in certain epidemics of a decidedly malignant character. 

SECTION V.— CHRONIC METRITIS. 

By chronic metritis, Imeaji_here a chronic inflammation of the womb, 
whether the result of the acute form of the disease, or arising as an 
original affection, and liable to involve all its tissues, but especially its 
lining mucous membrane, and the neck of the organ. 

Chronic metritis may occur in the puerperal state, but is by no means 
especially liable to occur in that condition, a large majority of the cases 
which have fallen under my observation having been independent of the 
puerperal state. The disease, however, in whatever condition it occurs, 
is attended with a train of symptoms which we will now proceed to con- 
sider. 



676 DISEASES OP THE GENITAL ORGANS. 

Symptoms. — The symptoms of chronic metritis, when not the result 
of the acute form of the disease, are in some cases rather obscure. 
Generally, however, the patient experiences a sense of heat, pain, and 
soreness in the middle and lower part of the pelvis, in different portions 
of the womb, and in some cases, a sense of weight is felt, attended 
with pain in the upper part of the vagina, as if the uterus were pro- 
lapsed. 

In nearly all cases of this disease, there is more or less leucorrhoeal 
discharge, and if from any cause the inflammation is increased, the dis- 
charge may assume a purulent character. And on examination with 
the speculum and by the touch, the neck of the womb is often found 
red, swelled, and tender to the touch. 

More or less pain is experienced in the back, and the stomach sym- 
pathizes with the womb, in most cases giving rise to a train of very 
harassing dyspeptic and nervous symptoms. And patients suffering 
from this affection become nervous, fretful, irritable, desponding, and 
difficult, especially if they have been much on their feet, or riding over 
rough roads. 

In some cases the inflammation continues on for several months, or 
even years, without any serious structural change of the womb, but it is 
liable, among other structural changes, to become indurated, scirrhous, 
and finally to pass on to cancerous ulceration. 

Diagnosis. — The existence of chronic metritis should always be sus- 
pected, in cases of leucorrhoea, attended with heat, weight, soreness and 
pain in the upper part of the vagina. If now in addition to this, there 
is the heat, pain and soreness in the uterus itself with the gastric and 
other sympathetic derangements which attend chronic metritis, the di- 
agnosis is rendered clear and positive. 

Causes. — Chronic metritis is sometimes the result of the acute form of 
the disease. It may also be the result of difficult or instrumental labors, 
as well as of frequent abortions. The disease is sometimes produced by 
masturbation, or excessive sexual indulgence, or it may be the result of 
a gouty or rheumatic condition of the organ, or of amenorrhcea, or of 
the final cessation of the menstrual function. And the disease is liable 
to be produced by exposure to cold and dampness, as well as by most of 
the influences which cause chronic inflammation in other organs or parts. 

Treatment. — The first step in the treatment of chronic metritis is to 
remove the cause or imprudence which has led to it, as far as possible, and 
to correct the habits of the patient in every respect. 

Two or three blue pills may be given at first, and followed by half an 
ounce of the sulphate of magnesia, after which the bowels may be kept 
loose by a teaspoonful, administered in the morning, two or three times 
per week. 

Cups should be applied to the sacrum and hypogastrium, and an ounce 
or two of blood taken once or twice per week, if the system is in a con- 
dition to admit of it, till the disease is in a good degree subdued. 

As an alterative in such cases, the iodide of potassium may be given 
in five grain doses three times per day, before eating, and continued 
till, with the other treatment suggested, the chronic uterine inflamma- 
tion is subdued. 



DISEASE OF THE CERVIX UTERI. 677 

The patient should be directed to keep quiet, or at least to avoid long 
walks, or riding in a carriage over rough roads ; and in cases in which 
the os uteri is seriously involved in the inflammation, and it is not subdued 
by the treatment already suggested, a solution of the nitrate of silver, of 
the strength of 40 or 60 grains to the ounce of water, may be applied 
through a speculum with a sponge twice each week, till a cure is effected. 

SECTION VI.— DISEASE OF THE CERVIX UTERI. 

By disease of the cervix uteri Lraean here a morbid condition of the 
neck of the womb, whether congestive, inflammatory, or malignant, 
generally chronic, and always attended with more or less constitutional 
derangement. 

We have seen, in the preceding section, that the neck of the womb is 
very liable to be involved in chronic inflammation with the whole organ. 
We are now to see that the neck is liable to become the exclusive seat 
of chronic disease, of a benign or malignant character. 

The disease, in cases of this character, whether it be simple conges- 
tion, inflammation, or of a scirrhous character, generally involves that part 
of the neck of the womb which projects into the vagina, including the 
mucous lining of the canal of the cervix. 

Now, disease of the cervix uteri may exist for a long time in so insidi- 
ous a manner as to be overlooked, unless proper discrimination is exer- 
cised, the various sympathetic affections absorbing all the attention of 
the patient and her friends, the primary source of the deranged health 
not being even suspected in some cases. And this is not strange, when 
we remember the tremendous influence which the womb exerts on the 
female system, both through the cerebro-spinal and sympathetic nerves. 

Bearing these facts in mind, we will proceed to consider the symp- 
toms of the disease of the cervix uteri, whether congestive, inflammatory 
or malignant, together, as the sympathetic derangements are liable to be 
very similar in all cases, the local being sufficient to enable the careful 
observer to discern the nature of the primary disease of the cervix, in 
most cases at least. 

Symptoms. — In cases in which the neck of the womb is congested, 
irritated, or slightly inflamed, with a state of irritation or inflammation 
of the lining membrane of the cervix, there is apt to be an albuminous 
discharge, which may be distinguished from the vaginal leucorrhceal 
discharge by its albuminous appearance, resembling very much the white 
of an egg. A feeling of heat, fullness, and sometimes of slight pain, 
is experienced in the region of the cervix, especially for a few days pre- 
vious to menstruation. 

The patient becomes nervous, irritable and desponding, in most cases, 
and very often hysterical ; all these and other sympathetic symptoms 
being usually greatly increased or aggravated for a few days before 
the menstrual flow, the uterine tendency doubtless increasing the local 
congestion, irritation or inflammation in the neck of the womb. 

There is generally a pain or feeling of heaviness in the sacral and 
lumbar region of the spine, and in most cases a feeling of heat, uneasi- 
ness, and sometimes of slight pain along the spine at different points 



678 DISEASES OF THE GENITAL ORGANS. 

and also in the cerebellum or back part of the head. The stomach also 
sympathizes strongly with this local irritation, the appetite being variable 
and the digestion often but poorly performed, and in bad cases, nausea, 
wretching and vomiting is liable to occur at times. 

There is in many cases uneasiness in voiding urine, and more or less 
pain felt in the lower part of the pelvis, at each movement of the 
bowels. Thus the disease passes on, the local and general symptoms 
being gradually more troublesome, till the patient becomes habitually 
nervous, irritable, petulent, and hysterical; and if the disease continues 
perhaps becomes insane. 

If now the finger be passed along the vagina, so as to touch gently 
the neck of the womb, the patient complains of pain ; and a fullness, 
pufimess, or enlargement of the cervix may be detected. And if an ocular 
inspection be made, by means of a speculum, in a clear light, more or 
less redness will be discovered in all that portion of the cervix which 
extends into the vagina ; and not unfrequently an albuminous fluid may 
be discovered adhering to the extremity of the cervix, at the orifice of 
its canal. 

It is well in such cases to examine the orifice of the urethra ; for a 
slight tenderness or irritation at that point will sometimes alone develop 
nearly all the symptoms which I have described as arising from irrita- 
tion of the cervix uteri, and, in addition, the most excruciating pain is 
experienced in passing water. 

Both these conditions may and frequently do exist in the same 
patient, for a long time, developing the most unpleasant local symp- 
toms, and sympathetic constitutional derangements of a nervous or hys- 
terical character. 

Malignant disease of the cervix uteri is usually attended with the 
same train of sympathetic derangements, and general symptoms, which 
belong to the benign or simple form of disease of this part. There is, 
however, in malignant cases also the scorbutic or cachetic appearance 
of the patient, emaciation and general debility, the sanious or bloody 
discharge, and the indurated and sometimes lobulated, and, perhaps, 
ulcerated condition of the cervix, which is readily discoverable by tac- 
tile and ocular inspection. 

Diagnosis. — Disease of the cervex uteri may generally be distin- 
guished by the troublesome train of constitutional or sympathetic symp- 
toms, which I have enumerated, such as dyspepsia, nervous irritability, 
petulence, hysteria, &c, together with the feel and appearance of the 
cervix, and the presence of an albuminous, sanious or bloody discharge. 

Malignant disease of the cervix may be distinguished from the simple 
or benign by the cachetic countenance, the emaciation and general de- 
bility, the indurated or perhaps ulcerated condition of the cervix, and 
by the sanious or bloody discharge, none of which symptoms necessarily 
belong to the benign form of the disease. 

Causes. — A great variety of causes may operate to produce disease 
of the neck of the womb. 

A rheumatic condition of the system evidently predisposes to this 
affection, especially if the uterus be the chief seat or point of the rheu- 
matic irritation. 



DISEASE OF THE CERVIX UTERI. 679 

But anions: the exciting causes of disease of the cervix uteri, I am 
satisfied, from careful inquiry on this subject, that masturbation and 
excessive sexual indulgence, especially at the menstrual period, or too 
soon after confinement, together with frequent abortions, are by far 
the most frequent causes of the non-malignant form of the disease. 
And further, that the malignant form of the disease is generally the 
result of the long continuance of the benign, in constitutions of a scor- 
butic or scirrhous predisposition. 

Prognosis. — The prognosis in non-malignant disease of the cervix 
uteri is generally favorable, if the causes which have been operating can 
be removed, and the patient is subjected to proper treatment in season. 
But in all cases of malignant disease of the neck of the womb, I need 
hardly say that the prognosis is decidedly unfavorable, as the case will 
generally pass on to a fatal termination. 

Treatment. — In all cases of disease of the cervix uteri, the real con- 
dition of the part should be ascertained, the causes which have been operat- 
ing to produce it or keep it up should be removed, and the patient made 
to conform to the laws of health and rules of propriety in every respect. 

If the bowels are constipated a teaspoonful of the sulphate of mag- 
nesia, or a Seidlitz powder may be given every morning till the bowels 
are regulated. Cups should be applied, wet or dry, along the sacral and 
lumbar region of the spine, and if necessary leeches to the hypogas- 
trium. 

By thus removing the cause, correcting the habits, regulating the 
bowels by saline laxatives, and occasionally applying cups and leeches 
if necessary, simple congestive or inflammatory cases may very often 
recover without further treatment. If, however, the disease continues, 
and there is a rheumatic condition of the system, five grains of the iodide 
of potassium should be given three times per day, before each meal, and 
continued till the rheumatic condition is removed as far as it may be. 

If, now, when all the general indications have been thus fulfilled, the 
disease of the cervix still remains to some extent, and there is no evi- 
dence of malignancy, the cervix should be touched lightly k with the 
nitrate of silver in substance, or what may be safer in most cases, with a 
solution of the nitrate of the strength of from forty to sixty grains to 
the ounce of rain water. 

The application may be made in either case through a speculum. If 
the solid nitrate is used, a piece of it may be passed into a quill, and 
made fast, when in a good light the diseased part of the cervix may be 
very rapidly passed over by the caustic, so as to change without destroy- 
ing the diseased surface. If, however, the solution is used, it may be 
conveniently applied by means of a sponge, firmly fastened about the 
extremity of a stick or whale-bone. This is readily passed through a 
cylindrical speculum, properly adjusted, and should be pressed gently 
upon the diseased cervix, and if it be found to have produced too much 
irritation of the diseased part, a soft moist sponge, with which the other 
end of the stick or whale-bone should always be armed, may be passed, 
and thus the application be diluted, and partially absorbed or removed. 

It is generally sufficient to make the application once each week, till 
the disease is removed. It should be made in the morning, and at even- 



680 DISEASES OF THE GENITAL ORGANS. 

ing an ounce of flax-seed tea, with twenty drops of laudanum may be 
thrown into the vagina, to quiet any undue irritation that may have 
been produced, or which is liable to arise from the application. A few 
applications will generally be sufficient to effect a cm-e, but if the case 
is improving, the treatment should be continued as long as may be re- 
quired. 

If in cases of this disease the mucous membrane at the orifice of the 
urethra is found inflamed and tender, as is sometimes the case, the part 
should also be touched by the solid caustic or solution till the irritation 
subsides. 

In disease of the cervix uteri of a malignant character, the same course 
of general treatment may be best, with the addition if necessary of tonics, 
but local applications except to cleanse and soothe the parts should not 
be used, as they generally rather hasten the destructive progress of the 
disease. 

SECTION VII.— LEUCORKHCEA. 

By leucorrhoea, from %tvxos, "white," and p £W , "I flow," jg here meant 
a white, yellowish, or greenish discharge, of a mucous, albuminous, or 
purulent character, from the vagina of the female. 

This discharge may depend upon a general or constitutional cause, or 
it may be the result of relaxation, congestion, irritation, or chronic in- 
flammation of the mucous lining membrane, of the female genital organs, 
and especially of that of the vagina, and of the canal of the cervix 
uteri. 

The general or constitutional condition, capable of producing, and keep- 
ing up this discharge, is probably a weak state of the blood, and a general 
deranged condition of the fluids, and solid tissues of the body. Especially 
does the rheumatic diathesis tend to the production of this discharge. 

While a general relaxed and debilitated condition of the solids, and a 
deranged state of the fluids of the body, may sometimes be the cause of 
a leucorrhoeal discharge ; it is probable that this general deranged con- 
dition, is often the result of the wasting discharge, which was at first 
set up by a local cause, operating upon the lining membrane of the 
female genital organs. 

The discharge then, generally proceeds from the mucous membrane of 
the vagina, of the canal of the cervix uteri, or else in some cases, proba- 
bly from the lining membrane of the uterus itself, and always depends 
upon a morbid condition of the lining mucous membrane, of some one of 
these parts, when it is not the result of a general constitutional derange- 
ment, as we have already seen. 

The morbid local condition then, upon which this discharge depends, 
may be relaxation, congestion, irritation, or a peculiar chronic inflamma- 
tion of that portion of the lining mucous membrane of the female genital 
organs, from which the discharge proceeds. 

When the matter of a leucorrhoea is of a mucous or purulent character, 
it generally comes from the mucous membrane of the vagina, being 
generally of a lightish mucous appearance at first, and assuming a yel- 
lowish or purulent character in the advanced, or more chronic stage of 



LUCORRHCEA. 681 

the disease. If, however, the discharge is of an albuminous character, 
appearing very much like the white of an egg, it generally comes from 
the canal of the cervix, or else from the membrane, lining the cavity of 
the womb itself, as it probably does in some cases. 

Now bearing these facts in mind, we will proceed to the consideration 
of the symptoms, which are developed in this disease. 

Symptoms. — The symptoms in those cases, which come on from general 
or constitutional causes, are those of general debility ; the patient being 
ansemic, pale, nervous, irritable, and generally suffering from slight 
rheumatic, or chronic neuralgic affections. After these symptoms have 
continued for a time, a slight mucous discharge occurs from the vagina, 
which gradually increases, till it becomes copious, sooner or later assum- 
ing a yellowish appearance, or sometimes even a greenish tinge, after it 
has continued for a long time. 

As the discharge becomes copious, and continues for a long time, the 
general debility, irritability, nervousness, and all the sympathetic de- 
rangements and general disturbances of the system, are greatly increased. 
Digestion becomes impaired, the menstrual discharge, at first, dimin- 
ished, is sometimes finally suspended, and if the disease passes on un- 
checked, scrofula, consumption, or some other fatal malady, is liable to 
lead on to a fatal termination. 

In those cases of leucorrhcea which occur from a relaxed, congested, ir- 
ritated, or inflamed condition of the mucous membrane of the vagina, with- 
out at first any marked constitutional debility or derangement, there is 
generally at first a slight uneasiness with heat in the vagina, followed soon 
by a more or less copious mucous discharge. After a time the discharge 
assumes a yellowish or purulent character, a dragging pain is felt in the 
sacral and lumbar regions, sharp darting pains pass down the limbs, 
menstruation becomes painful, the discharge being gradually lessened, 
and finally suspended in some cases ; the patient becomes nervous, irri- 
table, and dyspeptic, and unless the disease be arrested, some serious 
local or constitutional affection, with a rapidly fatal tendency is the result. 

In cases in which the discharge is from the mucous lining of the canal 
of the cervix, or of the cavity of the womb, the same train of symptoms 
usually attend in an aggravated form ; the discharge, however, instead 
of being of a mucous or purulent appearance, is of an albuminous char- 
acter, appearing, as we have already seen, like the white of an egg. In 
all cases of this character, in which the discharge gradually assumes a 
watery, sanious, or bloody appearance, malignant disease of the cervix 
or body of the womb should be suspected, and a careful inquiry should 
be made into the condition of the suffering organ. 

Such, I believe, are the ordinary symptoms of leucorrhoea, occurring 
in consequence of a general derangement of the system, or from a local, 
relaxed, congested, irritated, or inflamed condition of the lining mucous 
membrane, of the female genital organs, of the vagina, canal of the 
cervix, or of the uterus itself, with the peculiarities belonging to each. 

Causes. — Leucorrhoea may be produced by any cause capable of pro- 
ducing a general debilitated condition of the system, or a morbid relax- 
ation, congestion, irritation, or inflammation of the mucous membrane 
of the vagina, or canal of the cervix uteri. A great variety of causes 



682 DISEASES OF THE GENITAL ORGANS. 

then may operate to produce this disease, including almost every im- 
prudence and exposure to which females are addicted or liable. 

But it is probable that among these causes the most frequent are mas- 
turbation, excessive sexual indulgence, difficult parturition, frequent 
menorrhagia, prolapsus uteri, the abuse of emmenagogues, a loaded and 
torpid state of the bowels, tight dressing about the waist, the depressing 
mental emotions, metastasis of rheumatism, atmospheric influences, sup- 
pressed hemorrhoids, and all the influences which operate to produce 
chronic inflammation of the cervix uteri. 

Diagnosis. — To distinguish leucorrhcea from gonorrhoea is often ex- 
tremely difficult, or even impossible ; the symptoms of acute leucorrhcea 
and gonorrhoea, in many cases, being precisely alike. 

In such cases, the only reliable means of diagnosis will be the general 
circumstances of the case, and the probability of the patient having been 
exposed to gonorrhoea. After thus having brought in all the evidence 
in the case, if there is a slight probability of the disease being gonorrhoea, 
it should be treated as such, as a protracted gonorrhoea might lead to 
very unpleasant consequences, especially if the disease occurs in a mar- 
ried female. 

To distinguish uterine from vaginal leucorrhcea, it is only necessary 
to take all the symptoms into the account, and to notice carefully the 
appearance of the discharge, the uterine being albuminous, sanious, or 
bloody, while the vaginal is of a mucous or purulent character. 

Prognosis. — The prognosis in all cases of leucorrhcea, not associated 
with organic disease of the female genital organs is favorable, if the 
causes can be removed, and the patient subjected to proper treatment in 
season. But in very protracted and obstinate cases, in which the dis- 
charge, at first albuminous, becomes watery, sanious, or bloody, serious 
apprehensions may be had of the supervention of organic disease, and of 
a fatal termination of the case. 

Treatment. — The treatment of all cases of uterine leucorrhcea should 
consist in a removal of the cause regulating the bowels, and general con- 
dition of the patient, the application of cups to the sacrum and lumbar 
region of the spine, the administration of iodide of potassium for a time, 
and, if necessary, the application of the nitrate of silver, in substance or 
solution, to the neck of the womb, followed by a mucilaginous and ano- 
dyne injection into the vagina, once each week, till a cure is effected, as 
suggested in the preceding section. In such cases, when the uterine 
disease is thus subdued, the leucorrhceal discharge will generally cease, 
and not before. 

In acute cases of vaginal leucorrhcea, depending upon sudden expo- 
sure to cold, dampness, &c, constipation of the bowels, or any sudden 
cause, as a local injury, with only a slight predisposition to the disease, 
it may often be arrested by three blue pills administered at evening, and 
followed in the morning by half an ounce of the sulphate of magnesia, 
the bowels then being kept loose by a teaspoonful taken each morning 
for a time. The patient should, however, be kept clean and warm, and 
two or three ounces of blood may be taken by cups from the sacral and 
lumbar region, and then dry cups applied occasionally, the genital parts 
being kept clean and cool by injections of moderately cold water, morn- 
ing and evening. 



LEUCORRHCEA. 683 

This course of treatment alone will frequently arrest leucorrhoea, de- 
pending upon sudden accidental causes. Should the discharge continue, 
however, in addition to what I have suggested, twenty drops of the 
balsam of copaiva should be given, three times per day, after each meal, 
and continued for a reasonable time. 

Should the disease not yield, and pass on and become chronic, and in 
all chronic cases depending upon general or local causes, five grains of 
the iodide of potassium should be administered, three times per day, 
before meals, the balsam of copaiva being given in twenty drop doses 
after eating. After the iodide of potassium has been given for a few 
weeks it should be discontinued, and the syrup of the iodide of iron 
given instead, in ten drop doses, and this should be continued in connec- 
tion with the balsam of copaiva in ten drop doses, with the addition, if 
necessary, in protracted cases, of injections of alum, morning and even- 
ing, of the strength of one or two drachms to the pint of rain water, till 
a cure is effected. Or in cases attended with great relaxation of the 
mucous membrane of the genital organs, injections of tannin of the same 
strength may be used instead. 

In cases of leucorrhoea attended with, and in part depending upon 
prolapsus uteri, the same general treatment may be adopted that I have 
already suggested, but in addition, measures should be taken to restore 
the womb to its original position, and keep it there, as nearly as may be. 

The patient, in such cases, should have all her underclothes suspended 
by the shoulders, to prevent any dragging down of the bowels, should 
lay at night with her hips high, should press the bowels up occasionally, 
and manipulate the lower portion of the abdomen, to give tone to the 
abdominal muscles, and in very bad cases, may wear a pad across the 
lower part of the abdomen, for a time, or a pessary introduced into the 
vagina. Should a pessary become necessary, I prefer that invented by 
my preceptor and former partner, Dr. Wm. V. V. Rosa, of Watertown, 
N. Y., as being the most safe, convenient and reliable of any that have 
fallen under my observation. 

This pessary was first used by us in several desperate cases in Jeffer- 
son county, in this State ; is now manufactured in New York, and kept 
for sale by Drs. Smith and Pratt, druggists, and eminent practitioners 
of medicine and surgery, of Canandaigua, N. Y. It is composed entirely 
of silver, and consists of a pessary, of smallish size, but of the shape of 
the common glass pessary, perforated in its centre to receive a double 
silver canula, which may be lengthened or shortened to suit the length 
of the vagina. 

The womb should first be put in its place, the pessary then introduced 
and carried up to the neck of the womb, after which the double canula 
should be carefully screwed in, and its length properly adjusted, so that 
its lower end shall reach the lower extremity of the vagina ; to this two 
small chains, wound with cotton, are fixed, one of which is hooked ante- 
riorly, and the other posteriorly, to a belt above the hips. 



684 DISEASES OF THE GENITAL ORGANS. 

SECTION VIII.— AMENORRHEA. 

By amenorrhoea, from a, privative, p^v, "a month," and p f u, " I flow," 
is here meant a retention or suppression of the menses, usually in conse- 
quence of some local or constitutional derangement of the system. 

The disease may consist, then, of retention of the menses, in which 
case there is a failure to establish the menstrual function ; of suppres- 
sion, or an interruption to the function after it has been established, and 
may be attended, in either case, with a vicarious discharge from the 
nose, lungs, stomach, or some other part, constituting what has been 
called vicarious menstruation. 

Bearing these facts in mind, we will proceed to the consideration of 
this disease, and first of the symptoms which are developed in its various 
forms. 

Symptoms. — When the young female arrives at the age of puberty, 
and the ordinary changes take place in the system, such as enlargement 
of the breasts, the growth of hair upon the pudenda, &c, and yet the 
menstrual functions is not established, the failure may be in degree, but 
sooner or later a train of morbid symptoms are apt to be developed. 
There is headache, a flushed countenance, pains in the back and limbs, 
and a full and either slow or accelerated pulse ; and there is evidently, 
in these cases, a torpor of the uterine vessels, in consequence of which 
they fail to produce the menstrual discharge. Such patients have gene- 
rally been accustomed to sedentary habits, high living, hot rooms, soft 
beds, and too much sleep, and hence their general plethora, and also the 
retention of the menses on their arriving at the age of puberty. 

In anaemic females, on the other hand, there is sometimes a failure in 
the establishment of the menstrual discharge, as the age of puberty 
approaches, attended with more or less derangement of the health, as 
the system appears to make an ineffectual effort. The patient becomes 
emaciated, the face and lips are pale, the hands and feet are cold, the 
tongue is foul, the appetite is variable, the bowels are constipated, and 
the pulse slow and feeble ; and if the retention continues for a long time, 
the girl becomes desponding, hysterical, and decidedly melancholy in 
most cases. There is often nervous palpitation of the heart, dyspepsia, 
and, only a slight over exertion in some cases, produces a short, dis- 
tressing cough. 

In these anaemic cases, in which the cause of the retention is directly 
the opposite condition of the system to the plethoric cases before referred 
to, the patients have generally been delicate during childhood, confined 
in close apartments, subject to depressing passions, and in some cases to 
the habit of masturbation. 

Thus we have retention of the menses, at the age of puberty, from 
directly opposite causes, and in widely different conditions of the system, 
in the one case the patient being plethoric, of full habits, and fleshy, 
while in the other the patient is anaemic, thin, pale, nervous, irritable, 
and melancholy. 

Now, in those girls in which neither of these morbid conditions exist 
at puberty, in our climate, generally at about the age of fourteen or fif- 
teen, the menstrual discharge is established, and continues with great 



AMENORRHEA. b85 

regularity every four weeks till about the age of forty-five, when it is 
suspended, with little or no derangement of the health. 

During the period from the age of fifteen to forty-five, suppression of 
the menses is liable to occur from pregnancy, and it is also liable to 
occur from various derangements of the system, the discharge being 
either suddenly arrested at a menstrual period, or else gradually lessened, 
till complete suppression takes place. 

In cases of chronic suppression, occurring gradually, no very marked 
symptoms are developed, as the immediate result of the suppression, the 
symptoms depending rather upon the condition of the system which led 
to it, the discharge appearing to cease in consequence of the debility of 
the patient, the system either not requiring the discharge, or else not 
having the ability to produce it. But if, as sometimes happens, from 
exposure to cold, during the menstrual period, the discharge is suddenly 
arrested, the most violent local and constitutional symptoms are liable 
to be developed. 

In such cases, immediately on the cessation of the menstrual discharge, 
the patient complains of severe pain in the region of the womb, which 
extends to the spine, giving the most severe distress in the sacral and 
lumbar region, the pain in some cases passing up the spine to the brain, 
and being attended with cephalic irritation, congestion, and sometimes 
with the most terrible convulsions. The cephalic irritation which attends, 
if not overcome, is liable to pass on to inflammation, effusion, &c. ; and 
more or less nausea and vomiting generally attends, in cases of suppres- 
sion of this character. 

Vicarious menstruation is liable to occur in cases of amenorrhoea, in 
which a deranged condition of the uterus is the cause of the retention or 
suppression. In such cases, the system failing to relieve itself of the 
discharge by the uterus, which its healthy condition requires, a vicarious 
discharge is set up in some other part, which may recur with great regu- 
larity every four weeks, till the uterine discharge is restored. 

The escape of blood in vicarious menstruation, is liable to take place 
from any part of the body from which ordinary hemorrhage may occur, 
but it generally takes place, according to my observation, from the nose, 
lungs, stomach, or bowels, numerous instances of which have fallen under 
my observation. The loss of blood maybe slight in such cases, and 
attended with no very serious local or general symptoms, or the hemor- 
rhage may be of a frightful character, in some cases even endangering 
the life of the patient. 

Such, I believe, are the ordinary symptoms of amenorrhoea, from reten- 
tion and suppression, with or without vicarious menstruation. 

Causes. — The causes of amenorrhoea, as we have already seen, are 
such as produce retention or suppression of the menses, retention gene- 
rally being attended with either a full plethoric habit, or else an anaemic 
condition of the system. 

Suppression may be produced by similar conditions of the system, as 
we see in chronic cases, which take place gradually ; or it may occur 
suddenly during the menstrual period, from sudden exposure to cold, 
dampness, &c. 

Pregnancy is also a cause of amenorrhoea, and should be suspected 



686 DISEASES OF THE GENITAL ORGANS. 

when there is no other sufficient apparent cause. It should be remem- 
bered, however, that menstruation sometimes goes on for several months 
after conception. Such cases are, however, an exception to a rule, as 
menstruation should cease during pregnancy. 

The remote causes of amenorrhcea are too numerous to be mentioned, 
including inherited constitutional imperfections, and almost every im- 
prudence and accident to which females are addicted or liable. I 
believe, however, that the most frequent causes are imprudence in eat- 
ing and drinking, sedentary habits, constipation of the bowels, indo- 
lence, or extreme want, neglected or disappointed affections, self-pollu- 
tion, and sudden exposure to cold or dampness during the menstrual 
flow. 

Vicarious menstruation, occurring as it does in constitutions which 
require the discharge, generally depends upon an inherited or acquired 
defect on the part of the uterus itself; the vicarious discharge taking 
place from the nose, lungs, stomach, bowels, or other parts which from 
constitutional or accidental circumstances is most predisposed. 

Treatment. — The treatment of amenorrhcea requires the exercise of 
the greatest degree of prudence, discretion, and good common sense. 

As a general rule those cases of retention occurring in girls arrived 
at the age of puberty should not be regarded as requiring treatment, 
unless there is an evident impairment of the health, calling for medical 
aid. If, however, there is a derangement of the general health, appa- 
rently in consequence of the non-appearance of the menstrual discharge, 
and the patient is either of the plethoric or anaemic condition, which I 
have described, a course of medical treatment is indicated, and should 
not be neglected. 

If the case be one of plethora, with constipation of the bowels, and a 
decided cephalic tendency, with an apparent ineffectual effort at men- 
struation, a full dose of calomel should be administered at first, and 
followed with half an ounce of the sulphate of magnesia. 

After the bowels have been freely evacuated by the cathartic, a pill 
of aloes and rhubarb should be given each day, after dinner, and con- 
tinued, to regulate the bowels, and also to overcome the cephalic ten- 
dency. It also at the same time acts as a mild emmenagogue. 

Cups may be applied over the sacrum, and along the lumbar region 
of the spine, and two or three ounces of blood taken, if the case appears 
to require the abstraction of blood, as it sometimes does. 

The patient should be made to correct every imprudent habit, and 
should be placed upon a plain, digestible, and unstimulating diet ; 
should be made to sleep on a hard bed, to take sufficient exercise in 
the open air, &c. And when the effort at menstruation occurs, the 
warm foot-bath should be used, for two or three evenings, and sina- 
pisms applied to the lumbar and sacral regions of the back, on going 
to bed at night. In this way the menstrual discharge will frequently 
be established without further treatment. But if when the general 
phlogistic condition of the system is overcome, and the bowels regu- 
lated, the menstrual discharge is not established, Dewees' tincture of 
guaiac should be given, in teaspoonful doses, three times per day, im- 
mediately after eating, in a little sweetened milk ; and this should be 



AMENORRHEA. 687 

continued, with the pill of aloes and rhubarb after dinner, till the 
menses appear. 

In anaemic cases, in which there is retention of the menses at the age 
of puberty, with an ineffectual effort on the part of the system to bring 
about the menstrual discharge, a judicious course of treatment should 
be pursued. Two or three blue pills may be given at first and followed 
by a Seidlitz powder, or the sulphate of magnesia, to secure a free 
motion of the bowels ; after which a pill of aloes and rhubarb should 
be given each day, after dinner, and continued till the bowels are 
regulated. 

As soon as the bowels are regulated, Dewees' tincture of guaiac, 
should be given in teaspconful doses, three times per day, after eating, 
and if, as is often the case, iron is indicated, the syrup of the iodide 
should be given in ten drop doses, three times per day, before eating, 
and this should be continued with the guaiac, till the menses appear. 

The patient should take a good nourishing diet, and proper exercise, 
and as the effort of the system to establish the discharge, makes its ap- 
pearance, the warm-foot-bath should be resorted to, for two or three 
evenings, and sinapisms applied to the sacral and lumbar regions of the 
back, on retiring to bed at night. In this way, the system may gener- 
ally be corrected, and menstruation established, in a few weeks or months. 

Now the treatment for suppression of the menses, differs in nothing 
from that which I have laid down for retention, except in acute cases, 
occurring during the menstrual flow, from sudden exposure to cold, damp- 
ness, &c, the treatment of which it is necessary for us to consider. 

Acute or sudden suppression of the menstrual flow, from exposure to 
cold or dampness, at the menstrual period, requires active and immediate 
treatment, as violent congestion, irritation, or even inflammation of the 
brain is liable to occur. As soon then, as such a suppression occurs, at- 
tended with cephalic congestion, a full dose of calomel should be given, 
and that followed by half an ounce of the sulphate of magnesia, and a 
free action of the bowels secured. 

Cups should be applied to the back of the neck, and also to the sacral 
and lumbar regions, and a few ounces of blood taken, and this may be 
repeated, if the cephalic tendency continues. Warm pediluvia should 
be used, and to quiet nervous irritability, three grains of the solid extract 
of hyoscyamus, or fifteen drops of the fluid extract may be given, with 
two grains of camphor, every six hours, till quiet is restored. 

In plethoric patients, with violent cephalic symptoms, a full bleeding 
from the arm may be indicated, in some cases, and when it is, should not 
be neglected. After the cephalic symptoms pass off, the patient should 
take a pill of aloes and rhubarb, each day after dinner, should take a 
plain digestible, and unstimulating diet, with which treatment, in most 
cases, the menses will appear, at the next regular period. This should 
be favored by the warm foot-bath, for two or three evenings, and the 
sinapisms to the lower portion of the back, as the menstrual period ar- 
rives. If, however, with these measures, the menses do not appear, at 
the first regular period, the case should be treated according to the prin- 
ciples I have already laid down, for chronic retention or suppression of 
the menses. 



688 DISEASES OF THE GENITAL ORGANS. 

In cases of vicarious menstruation, in which the system failing to effect 
the discharge by the uterus, sets up a vicarious discharge from the nose, 
lungs, stomach, bowels or other parts ; immediate measures should be taken 
to bring about the uterine menstrual discharge, that the vicarious dis- 
charge may be suspended. 

In such cases, after removing the cause, regulating the bowels, &c, the 
tincture of chloride of iron should be given in ten drop doses three times 
per day, as a tonic emmenagogue, and to arrest the hemorrhagic ten- 
dency which probably favors the vicarious discharge. As an emmena- 
gogue to act directly upon the uterus in such cases, the tincture of can- 
tharides may be given in thirty drop doses, three times per day, to be 
continued in connection with the iron already suggested, as long as may 
be required. 

The patient should be directed to keep the feet warm and dry, and 
to use the warm foot bath, and sinapisms to the lower part of the back, 
beginning a day or two before the time for the periodical discharge. By 
this course of treatment, we may generally succeed in restoring the na- 
tural, and arresting the vicarious discharge in a few weeks or months at 
longest. 

In all cases of suppression of the menses in married females, it is most 
prudent to wait and be certain whether pregnancy may not be the cause, 
and thus avoid the possibility of producing an abortion, as well as the 
mortification of having prescribed for that which was really no disease. 
After sufficient time has elapsed to render it certain that the suppression 
is not from pregnancy, the case should be treated according to the prin- 
ciples already laid down. 

In all cases of suppression in unmarried females, the presumption is 
that pregnancy is not the cause, and as a general rule, this presumption 
is to be followed, unless signs of pregnancy are discovered. In case 
signs of pregnancy are discovered, however, as well as in cases in which 
though there may be no signs of pregnancy, there is no sufficient de- 
rangement of the health apparent, to account for the suppression, I be- 
lieve it is our imperative duty to wait, or if we make a prescription to 
be sure that it be one that can do no harm, should pregnancy prove to 
be the cause of the suppression. If unmistakable signs of pregnancy 
are discovered, the fact may be kindly suggested to the patient, and 
such advice offered in relation to immediate matrimonial arrangements, 
as the case may appear to require, but the patient should be solemnly 
warned in all cases, not to attempt or even desire an abortion, either of 
which constitutes a crime of the deepest dye. 

SECTION IX.— DYSMENORRHEA. 

By dysmenorrhcea, I mean_her_e painful or difficult menstruation, an 
affection by no means very uncommon in females of a peculiar and deli- 
cate constitution. 

Now in order to understand this subject, it is well to bear in mind 
the fact, that most females as the menstrual period approaches, feel 
more or less uneasiness along the lower portion of the spine, in the 
lumbar and sacral regions. This pain also extends in many cases, to 



DYSMENORRHEA. t>&9 

the lower portion of the abdomen, as well as to the uterus, and is very 
apt to pass down the limbs, following the track of the large nerves. 

Now this uneasiness is doubtless owing to a slight congestion of the 
spinal cord, in consequence of which the uterine and other nerves more 
immediately connected with this portion of the spine become slightly 
irritated, a congestion of the uterine vessels occurs, the menstrual flow 
follows, and the uneasiness subsides. Even this slight pain is probably 
a morbid condition, consisting of a preternatural irritability of the sys- 
tem, in consequence of which the nervous influence sent out by the 
brain to set up the menstrual discharge, produces an undue degree of 
congestion, and more or less pain, before the discharge commences. 

Now in dysmenorrhcea, as the menstrual period approaches, there is 
a great aggravation of all these pains, which are only slight ordinarily, 
and various other general symptoms which we will now proceed to con- 
sider. 

Symptoms. — The prominent symptoms then of this affection are pain 
in the lower portion of the back or loins, extending more or less to the 
bowels, and down the limbs ; severe aching, bearing down, or grinding 
pains in the uterus, sometimes subsiding as the discharge commences, 
but in other cases continuing during the w T hole menstrual period. 

The flow is liable to be quite irregular, being almost suspended at 
times, and again coming forth very freely, with more or less coagulated 
blood, and sometimes a pseudo-membranous substance is thrown off, 
which appears to have occupied the whole inner surface of the womb. 

The pain, in some cases, very much resembles labor pains, and it 
may continue till the menstrual period has passed by, there being still 
left a dull heavy pain in the womb, and lower portion of the spine, which 
gradually pass off in a few days. In some cases, the uterine irritation 
is so great that the stomach strongly sympathizes during the severe 
pain, nausea and vomiting being an attendant symptom. The menstrual 
flow may continue of nearly its normal quantity, but it is liable, if the 
disease continues for a long time, to become greatly diminished. 

Such are the ordinary symptoms of this very troublesome affection, 
which may occur at any time during the menstruating period of female 
life, but more generally, I think, between the twentieth and thirtieth 
years of age, at least in cases that have fallen under my observation. 

Pathology. — There may be ground for doubt in relation to the nature 
of this disease, but it appears to me that it is generally of a rheumatic 
character, as it is very liable to occur in patients of a rheumatic di- 
athesis. In some cases, however, there is a contraction or partial 
closure of the canal of the cervix uteri, producing a mechanical obstruc- 
tion to the free passage of the menstrual fluid. This, however, may 
have been brought about, and probably is in most cases, by a slow in- 
flammation, of a simple or rheumatic character. 

If now, rheumatism depends upon either congestion, irritation, or 
inflammation of some portion of the brain or spinal cord, or their 
meninges, as I have suggested in a previous chapter, and generally 
congestion, then the rheumatic character of this affection may be readily 
explained. For it only requires a slight congestion or irritation in the 
lower portion of the spinal cord, to sufficiently irritate the uterine 
44 



690 DISEASES OF THE GENITAL ORGANS. 

nerves, if the womb is predisposed, to at first set up a neuralgic and 
then a rheumatic affection of the uterus. 

And that the disease once established should occur in paroxysms, 
during the menstrual period, is as we should expect, when we remember 
that not only the lower part of the spinal cord, but the uterus itself, at 
such times, is more or less congested. Nor is it strange that when this 
local rheumatic inflammation or irritation is of a certain grade, that a 
pseudo-membrane should be formed on the inner surface of the womb, 
or that if the disease be long continued, the canal of the cervix uteri 
should become contracted, and nearly or quite closed, as happens in 
some cases of this affection. 

I apprehend, then, that this affection is generally rheumatism of the 
uterus, coming on in the same manner, and from the same causes, as 
other chronic local rheumatic affections, a paroxysm being produced by 
the increased congestion and irritation of the lower portion of the spinal 
cord and uterus itself, at each menstrual period. Dysmenorrhosa may, 
however, in some cases, consist of simple neuralgia of the uterus, or it 
may depend upon congestion, or simple irritation or inflammation, of a 
non-rheumatic character. 

Treatment. — The treatment of dysmenorrhea consists in that which 
is proper, during the menstrual period, to quiet pain and promote relaxa- 
tion of the cervix uteri, and also that which is proper, during the inter- 
vals, to correct the morbid condition of the system, upon which the 
disease depends. 

The severe pain occurring during the menstrual period may generally 
be greatly relieved by cups applied along each side of the spine, in the 
lumbar region, and to the sacrum. To quiet pain and promote relaxa- 
tion of the cervix uteri, ten drops of the fluid extract, or twenty drops 
of the tincture of stramonium, may be given every six hours, in bad 
cases, till the pain subsides. As a drink, for a few days previous, and 
during the menstrual period, sulphur water, if at hand, is a valuable 
remedy, and will often prevent, or greatly lessen the pain during the 
menstrual flow. 

To break up this disease, or the morbid condition of the system upon 
which it depends, the habits of the patient should be corrected in every 
respect. Constipation of the bowels should be overcome by an occasional 
Seidlitz powder* and then the iodide of potassium should be given in 
five grain doses three times per day, before eating, in the fluid extract 
or compound decoction of sarsaparilla ; or in patients of a spare habit, 
in which the circulation is languid, the tincture of guaiac may be given 
instead of the iodide of potassium, in drachm doses, after each meal, and 
continued until a cure is effected. 

Dry cups, or pustulations with tartar emetic ointment along the lower 
portion of the lumbar and sacral regions, may sometimes be indicated. 
The diet should be plain, digestible, and taken with strict regularity, 
and the patient should wear flannel next the skin, and should avoid 
damp apartments, or exposure to cool, damp air. 

With this course of treatment judiciously applied, severe cases of this 
affection may generally be greatly relieved, and mild ones sometimes 
permanently cured. 



CONCLUSION. 691 

Thus I have completed what I had to say upon diseases of the gen- 
ital organs, which, with a few concluding remarks, will close this volume. 

CONCLUSION. 

Now, having completed this Treatise on the Practice of Medicine, 
a few reflections, suggestions, and a parting word with the reader, may 
be appropriate. They shall, however, be very brief. 

The reader ^vill remember that I commenced with the human system 
in health as the standard, and laid down the principle that disease 
should be considered in the light of deviations from this standard, and 
that in all cases the exact deviation should be taken, and from this the 
indications of treatment should be directly drawn ; that the indications 
being once arrived at in this way, the causes being removed, the most safe, 
convenient, and reliable remedies should be selected to fulfill these 
indications. 

With this view I discarded the idea of names for deviations or disease, 
any further than necessity might require ; and to keep the mind intently 
fixed upon conditions, instead of names, and because it was on every 
account proper, I announced that I should give the general anatomy and 
physiology of the different parts of the system, as I proceeded to take 
up the diseases to which they are liable. 

In accordance with my plans, after considering the nature, causes, 
symptoms, diagnosis, and treatment of disease, in my first chapter; irri- 
tation, congestion, and inflammation, in my second; the pathology, 
causes, and phenomena of fever in the third; general fevers in the fourth; 
cxanthematous fevers in the fifth, and general inflammatory diseases in 
the sixth, I proceeded to take up diseases of particular parts, in the fol- 
lowing order. In the seventh chapter, diseases of the nervous system, 
in the eighth, of the digestive system, in the ninth, of the respiratory 
system, in the tenth, of the circulatory system, in the eleventh, of the eye, 
in the twelfth, of the ear, in the thirteenth, of the skin, in the fourteenth, 
of the urinary organs, and finally, in the fifteenth, diseases of the geni- 
tal organs, in the precise order which I announced in my introductory. 

In considering the deviations from a healthy condition of these con- 
stituent parts of the human system, I have taken a general glance at 
their anatomy and physiology in health, and then by tracing their seve- 
ral diseased conditions, have attempted to draw the indications of treat- 
ment, that no prescription should be rendered empirical. 

It must not be supposed, however, that because all my prescriptions have 
been made to fulfill indications thus arrived at, that they have not been 
tested by experience, for they generally have, and are further, the ones 
which I have found the best adapted of any of the class to which they 
belong, to fulfill the several indications for which I have prescribed them. 
I have preferred thus to suggest only the best remedies to fulfill the indi- 
cations in each particular case ; thus avoiding the confusion from a mul- 
titude of inferior ones, especially as the student even will never find it 
difficult to arrive at a poorer remedy of a class, if from any accidental 
circumstance the best remedy should be contra-indicated, which is very 
seldom the case. 



692 CONCLUSION. 

And further, while I have preferred to give my own opinion of reme- 
dies, and in fact of almost every thing else of which I have treated, it 
has been from no feeling of ostentation, but simply because I believe I 
am better qualified to give my own opinion, than to hold up the opin- 
ions of other men, which in turn they can do much better than I could 
do it for them. But this certainly can detract nothing from the value 
of the work, as I am indebted to the good and wise, and great of the 
medical profession, as well as to my own observation in the treatment 
of disease, for the opinions which I hold in relation to the principles, 
science, and practice of medicine. 

And now, if in the effort which I have made, I shall succeed in in- 
spiring my brethren of the medical profession with a greater zeal for the 
restoration of the human family from the numberless ills to which they 
are exposed, in consequence of their disobedience of the laws of health, 
I shall be satisfied. If my suggestions in relation to the way and manner 
of doing this shall prove useful to the medical student and practitioners 
generally I shall be thankful. And finally, if we may, by our combined 
effort, but make a beginning which shall end in the physical, intellectual, 
and moral restoration of mankind, the end for which I have labored, and 
for which I shall ever pray, will have been accomplished. 

Let us then regard our high and holy calling, as ministers of life and 
health, as a sacred trust, and combine all our efforts for the end which 
I have suggested. Then may we become the feeble instruments in the 
hands of God, in bringing an apostate and degenerate race back to 
Himself ; and man, physically, intellectually, and morally reinstated, 
may really again bear the image of the Creator. 



INDEX 







PAGE 


PAGB 


Aerial Poisons, a cause of disease . 29 


Apncea, from strangulation, 




Ague. See Intermittent Fever 


94 


Treatment 


475 


Albuminuria. {B right's Disease 


) 630 


From irrespirable gases . 


. 475 


Symptoms, 


. 631 


Morbid appearances 


475 


Anatomical characters 


632 


Treatment 


. 476 


Diagnosis 


. 63 J 


From electricity . 


476 


Causes .... 


632 


Morbid appearances . 


. 477 


Nature 


# , 


. 632 


Treatment 


477 


Prognosis 




633 


From cold 


. 477 


Treatment 


. 


. 633 


Morbid appearances 


477 


Amaurosis . 




331 


Treatment 


. 477 


Symptoms 


. 


. 331 


Apoplexy .... 


254 


Diagnosis 




331 


Symptoms 


. 256 


Causes 


. 


. 331 


Diagnosis 


257 


Prognosis 




332 


Anatomical characters 


. 257 


Treatment 


. , 


. 332 


Prognosis 


258 


Amenorrhcea 




684 


Causes .... 


. 258 


Symptoms 


. 


. 684 


Pathology . 


259 


of vicarious 




685 


Treatment 


. 260 


Causes 


. . 


. 685 


Arteries, Inflammation of . 


514 


of vicarious 




686 


Arteritis .... 


. 514 


Treatment 


. 


. 686 


Symptoms . 


514 


Anaemia, (chlorosis) 




540 


Anatomical characters 


. 515- 


Symptoms 


. . 


. 540 


Causes 


515 


Diagnosis 




541 


Treatment 


. 515 


Causes 


. . 


. 541 


Arthritis. See Gout . 


216 


Nature 




542 


Ascites 


. 548 


Treatment 


. . 


. 542 


Symptoms . 


549 


Anasarca 




547 


of ovarian 


. 549 


Symptoms 


. 


. 547 


Diagnosis 


550 


Causes 




547 


Causes .... 


. 550 


Prognosis 


. 


. 547 


Prognosis 


551 


Treatment 




548 


Treatment 


. 551 


Aneurism of the Aorta . 


. 504 


Asphyxia. See Apncea 


471 


Anger, a cause of disease . 


27 


From drowning, 


. 472 


Angina Pectoris. See Neuralgi 


a of 


From strangulation 


474 


the Heart . 


. 511 


From irrespirable gases . 


. 475 


Animalcular Eruptions 


620 


From electricity . 


476 


Symptoms 


. 620 


From cold 


. 477 


Causes 


620 


Asthma .... 


458 


Diagnosis . * 


. 621 


Symptoms 


. 458 


Treatment . 


621 


of laryngeal 


459 


Aorta, Aneurism of 


. 504 


Causes 


. 459 


Apncea, {Asphyxia) 


471 


Pathology 


459 


From drowning 


. 472 


Prognosis 


. 460 


Morbid appearances 


473 


Treatment . 


460 


Treatment 


. 473 


Auscultation and Percussion . 


. 420 


From strangulation 


474 


Inspection . 


421 


Morbid appe 


irances . 


. 475 


Palpation 


. 421 



694 


INDEX. 






PAGE 




PARE 


Auscultation and Percussion. 




Bronchitis, Chronic, Treatment 


457 


Percussion 


. 421 


Bronchocele, ( Goitre) 


566 


Auscultation 


423 


Symptoms 


566 


Mensuration 


. 427 


Diagnosis .... 


567 


Succussion . 


428 


Causes .... 


' 56 I 


Auscultation of the Heart 


. 481 


Prognosis .... 


567 


Impulse 


483 


Treatment 


567 


Rhythm . 


. 483 






Sounds 


484 


Cancer of the Intestines 


366 


Impulse in disease . 


. 484 


Symptoms 


366 


Rhythm in disease 


485 


Anatomical characters 


366 


Sounds in disease 


. 485 


Diagnosis 


. 366 


Increased sounds 


485 


Treatment .... 


367 


Decreased sounds 


. 485 


Cancer of the Stomach 


. 351 


Murmurs 


485 


Symptoms .... 


352 


Regurgitation . 


. 486 


Anatomical characters 


. 352 


Anasmic murmurs 


486 


Diagnosis .... 


353 


Venous murmurs 


. 487 


Causes .... 


. 353 


Pericardial murmurs . 


487 


Prognosis .... 


353 


Mixed murmurs 


. 487 


Treatment 


. 353 


Percussion . 


488 


Canine Rabies. See Hydrophobia 


321 


In enlargement 


. 488 


Carditis . . - . 


. 496 


In pericardial effusion . 


488 


Symptoms .... 


496 


In aneurism 


. 488 


Diagnosis 


497 






Causes .... 


497 


Bilious Colic 


399 


Anatomical characters 


. 497 


Symptoms, 


. 399 


Treatment .... 


497 


Diagnosis 


400 


Catalepsy .... 


. 276 


Causes 


. 400 


Symptoms .... 


277 


Prognosis 


. 400 


Diagnosis 


. 278 


Treatment 


. 401 


Causes .... 


278 


Bilious Pneumonia 


438 


Pathology 


. 278 


History 


. 438 


Prognosis .... 


279 


Symptoms . 


439 


Treatment 


279 


Diagnosis, 


. 439 


Catarrh, Schneiderian 


441 


Causes 


439 


Symptoms 


. 442 


Treatment 


. 439 


Causes .... 


442 


Bilious Remittent Fever 


102 


Xature .... 


. 442 


Symptoms 


. 103 


Treatment .... 


443 


Type . .. . . 


103 


Catarrhal Ophthalmia 


568 


Gastric complications 


. 105 


Symptoms .... 


570 


Hepatic complications . 


105 


Diagnosis 


570 


Causes 


. 106 


Causes .... 


570 


Treatment . 


107 


Prognosis 


571 


Bladder, Acute Inflammation ( 


)f . 635 


Treatment .... 


571 


Bladder, Chronic Inflammatioi 


i of 637 


Causes of Disease . 


22 


Bloody Flux. See Dysentery 


. 359 


Predisposing Causes . 


23 


Brain. Inflammation of 


. _ 236 


Hereditary predisposition 


23 


Bright's Disease. See Albumi 


nuria 630 


Filth 


24 


Bronchitis, Acute . 


. 452 


Food, 


25 


Symptoms . 


453 


Clothing, 


26 


Diagnosis 


. 453 


Licentiousness . 


26 


Anatomical characters 


454 


Intoxicating liquors 


27 


Causes 


. 454 


Tobacco 


27 


Prognosis 


454 


Anger .... 


27 


Treatment 


. 454 


Exciting Causes 


27 


Bronchitis, Chronic 


455 


Heat .... 


27 


Symptoms 


. 455 


Cold .... 


28 


Diagnosis 


456 


"Water .... 


28 


Anatomical characters 


. 457 


Electricity 


29 


Causes 


457 


Light .... 


29 



INDEX. 



695 





PAGK 




PAGE 


Causes of Disease. 




Chorea, (St. Vitus' s Dance) 


280 


Exciting Causes. 




Symptoms . . . . 


280 


Aerial poisons . 


. 29 


Anatomical characters 


281 


Vegetable poisons 


30 


Diagnosis . . ... 


281 


Mineral poisons 


. 30 


Causes .... 


282 


Parasites 


30 


Pathology . . . . 


282 


Koino-miasmata 


. 31 


Prognosis .... 


282 


Idio-miasmata 


32 


Treatment . 


282 


Contagions 


. 32 


Circulatory System, Disease of . 


481 


Endemic influences 


33 


Circulatory System, Symptoms devel- 




Epidemic influences . 


. 34 


oped by .... 


38 


Causes of Fever . 


78 


Clap. See Gonorrhoea 


663 


Predisposing Causes 


. 78 


Clothing, Improper, a cause of dis- 




Hereditary predispositi 


on 78 


ease . . . . . 


26 


Indigestion 


. 70 


Cold, Apnoea from 


477 


Heat . 


79 


Cold, a cause of disease . 


28 


cold . ;. . . m . 


. 80 


Colic, Bilious .... 


399 


Various imprudencies 


80 


Colic, Flatulent . 


397 


Exciting Causes 


. 80 


Colic, Lead .... 


401 


Heat 


81 


Conclusion . . . . 


691 


Cold .... 


. 81 


Congestion .... 


54 


Humidity 


81 


Active Congestion . 


55 


Electricity 


. 81 


Passive .... 


55 


Koino-miasmata . 


82 


Causes of . . . . 


56 


Idio-miasmata . 


. 84 


Diagnosis .... 


56 


Contagious 


85 


Treatment . . . . 


56 


Cephalagia (Headache) . 


. 224 


Constipation .... 


407 


Causes 


226 


Symptoms . 


407 


Pathology 


. 226 


Causes .... 


407 


Treatment . 


226 


Treatment . 


407 


Cerebritis .... 


. 236 


Consumption. See Tubercular Phthi 




Symptoms . 


236 


sis 


463 


Anatomical characters 


. 237 


Contagions, a cause of disease 


32 


Diagnosis 


238 


Convulsions. See Eclampsia . 


304 


Causes . 


. 239 


Cornea, Inflammation of 


578 


Prognosis 


239 


Corneitis ..... 


578 


Treatment 


. 239 


Symptoms . 


579 


Cerebro-spinal Meningitis . 


250 


Diagnosis 


579 


Symptoms 


. 251 


Causes . . . 


579 


Anatomical characters 


252 


Prognosis 


580 


Diagnosis 


. 252 


Treatment .... 


580 


Causes 


252 


Cow-pox. See Vaccina . 


171 


Pathology 


. 253 


Croup. See Laryngo-tracheitis . 


449 


Prognosis 


254 


Crural Phlebitis 


518 


Treatment 


. 254 


Symptoms .... 


518 


Cervix Uteri, Disease of 


617 


Anatomical characters 


519 


Chicken-pox. See Varicella . 


. 174 


Causes .... 


519 


Chlorosis. See Anaemia 


540 


Treatment 


. 519 


Cholera Morbus 


. 388 


Cryptogamous Eruptions 


621 


Symptoms . 


388 


Symptoms 


. 622 


Causes . 


. 388 


Diagnosis .... 


623 


Diagnosis 


389 


Causes .... 


. 623 


Nature . 


. 389 


Nature .... 


624 


Treatment . 


389 


Treatment 


. 624 


Cholera, Malignant . 


. 390 


Cystitis, Acute .... 


635 


Cholera Infantum 


394 


Symptoms 


. 635 


Symptoms 


. 394 


Dissection .... 


636 


Anatomical characters 


395 


Causes .... 


. 636 


Causes . 


. 396 


Treatment .... 


636 


Nature 


396 


Cystitis, Chronic 


. 637 


Treatment 


. 396 


Symptoms .... 


637 



696 


INDEX. 






PAGE 




PAGE 


Cystitis, Chronic. 




Disease of the Cervix Uteri. 




Dissection . . 


. 637 


Diagnosis . . . . 


678 


Causes 


637 


Causes .... 


678 


Prognosis 


. 637 


Prognosis . 


679 


Treatment . 


638 


Treatment .... 


679 






Diseases, General Inflammatory 


206 


Dandy Fever. See Dengne 


. 203 


Dropsy. See Hydrops 


543 


Deafness, Nervous 


598 


Dropsy, Abdominal 


548 


Delirium Tremens. See Mania- 


a-potu 298 


Dropsy, General 


547 


Dementia, Insanity . 


288 


Dropsy, of the Chest 


552 


Dengne, {Dandy Fever) . 


. 203 


Dropsy, of the Brain . 


557 


Symptoms . 


203 


Dropsy, of the Heart 


555 


Diagnosis 


. 204 


Drowning, Apncea from 


472 


Causes . , 


204 


D}^sentery, [Bloody Flux) 


359 


Pathology 


. 204 


Symptoms .... 


360 


Prognosis 


205 


of chronic 


360 


Treatment 


. 205 


Diagnosis .... 


361 


Diabetes Mellitus 


638 


Causes . 


361 


Symptoms 


. 638 


Anatomical characters 


362 


Diagnosis 


639 


Prognosis . 


362 


Anatomical characters 


. 639 


Treatment .... 


362 


Causes . . , 


639 


Dysentery, Malignant 


363 


Nature 


. 639 


Dysmenorrhoea .... 


688 


Prognosis 


640 


Symptoms , 


689 


Treatment 


. 640 


Pathology .... 


689 


Diabetes Insipidus 


641 


Treatment . 


690 


Symptoms 


. 641 


Dyspepsia, [Indigestion) 


381 


Diagnosis 


642 


Symptoms . 


382 


Causes 


. 642 


Causes .... 


383 


Nature 


642 


Treatment . 


384 


Treatment 


. 642 


Dysuria, [Strangury) . 


653 


Diagnosis of Disease . 


43 


Symptoms . 


654 


Calls, attention to . 


. 43 


Causes .... 


654 


Question the messenger 


43 


Treatment . . . . 


654 


Inquire of the friends 


. 44 






Examination of the patien 


t 44 


Ear-ache. See Otalgia 


597 


Diarrhoea 


. 385 


Ear, Diseases of ... 


586 


Symptoms . 


386 


Ear, Symptoms developed by 


40 


Causes . 


. 386 


Eclampsia, [Convulsions) 


304 


Prognosis 


387 


Symptoms .... 


304 


Treatment 


. 387 


Causes 


305 


Digestive System, Disease of 


334 


Diagnosis .... 


306 


Digestive System, Symptoms 


devel- 


Prognosis . . . . 


306 


oped by 


. 37 


Treatment .... 


306 


Dilatation of the heart 


501 


Ecthyma. See Pustular Eruptions 


614 


Diphtheria 


. 154 


Eczema. See Vesicular Eruptions 


611 


Symptoms . 


155 


Electricity, a cause of disease . 


29 


Causes ... 


. 156 


Electricity, Apnoea from 


476 


Diagnosis 


157 


Emphysema 


479 


Anatomical characters 


. 157 


Symptoms .... 


479 


Nature 


158 


Anatomical characters 


480 


Prognosis 


. 159 


Causes .... 


481 


Treatment . 


159 


Treatment . 


481 


Disease, Causes of . 


. 22 


Endemic Influence, a cause of disease 


33 


Disease, Diagnosis of . 


43 


Endocardium, Inflammation of . 


493 


Disease, Nature of . 


. 17 


Endocarditis 


493 


Disease, Symptoms of 


34 


Symptoms .... 


493 


Disease, Treatment of 


. 46 


Diagnosis . . . . 


494 


Disease of the Cervix Uteri 


677 


Anatomical characters 


494 


Symptoms 


. 677 


Causes . 


495 


of malignant 


678 


Prognosis .... 


495 



INDEX. 



697 



Endocarditis. 


PAGE 


PAGE 

Eye, Symptoms developed by . 39 


Treatment 


. 495 


Eyeis, Protrusion of 


583 


Enteric continued Fevers . 


120 






Symptoms 


. 120 


Fainting. See Syncope 


. ' . 512 


Diagnosis 


121 


Favus. See Cryptogamous Eruptions 621 


Nature .... 


. 122 


Fever, Bilious Remittent 


. 102 


Anatomical characters . 


123 


Fever, Causes of 


78 


Causes .... 


. 123 


Fever, Enteric continued 


. 120 


Pathology . 


124 


Fever, Intermittent 


. . 94 


Prognosis 


. 125 


Fever, Pathology of 


. 67 


Treatment ... 


125 


Fever, Phenomena of . 


86 


Enteritis, Mucous . 


. 356 


Fever, Simple continued . 


. Ill 


Enteritis, Peritoneal . 


354 


Fever, Typhus continued 


129 


Epidemic Influences, a cause of 


dis- 


Fever, Yellow . 


. 138 


ease .... 


. 34 


Fevers, Exanthematous 


162 


Epilepsy .... 


268 


Fevers, General 


. 162 


Symptoms 


. 268 


Filth, a cause of disease 


24 


Anatomical characters 


270 


Flatulent Colic 


. 397 


Causes .... 


. 271 


Symptoms . 


397 


Pathology . 


272 


Diagnosis 


. 398 


Diagnosis 


. 273 


Prognosis 


398 


Prognosis 


273 


Treatment 


. 398 


Treatment 


. 274 


Food, a cause of disease 


25 


Epistaxis .... 


523 






Symptoms 


. 523 


Gases, Apncea from 


. 475 


Causes 


523 


Gastritis, Acute . 


346 


Prognosis 


. 523 


Symptoms 


. 346 


Treatment . 


523 


Anatomical characters 


347 


Equina. See Glanders . 


. 200 


Diagnosis 


. 347 


Eruptions and Rashes 


601 


Causes 


348 


Eruptions, Animalcular . 


. 620 


Prognosis 


. 348 


Eruptions, Cryptogamous . 


621 


Treatment . 


348 


Eruptions, Papular . 


. 609 


Gastritis, Chronic . 


. 349 


Eruptions, Pustular . 


614 


Symptoms . 


349 


Eruptions, Scaly 


. 617 


Anatomical characters 


. 350 


Eruptions, Vesicular . 


611 


Diagnosis 


350 


Erysipelas . 


. 186 


Causes 


. 351 


Symptoms . 


186 


Prognosis 


351 


of simple . 


. 186 


Treatment 


. 351 


of phlegmonous 


187 


General Fevers . 


94 


of malignant 


. 188 


General Inflammatory Diseases . 206 


Diagnosis 


192 


General Otitis 


586 


Anatomical characters 


. 192 


Symptoms 


. 589 


Causes 


192 


Diagnosis 


589 


Pathology 


. 193 


Causes 


. 589 


Prognosis 


194 


Prognosis 


589 


Treatment 


. 195 


Treatment 


. 589 


Exanthematous Fevers 


162 


Genital Organs, Diseases of 


656 


Exopthalmia . 


. 583 


Genital Organs, Symptoms developed 


Symptoms . 


584 


by . . . 


. 42 


Diagnosis 


. 585 


Glanders, {Equina) 


200 


Causes . 


585 


Symptoms 


. 200 


Prognosis 


. 585 


of acute 


200 


Treatment . 


585 


of chronic 


. 201 


External Otitis 


. 590 


Diagnosis 


202 


Symptoms . . . . 


590 


Anatomical characters 


. 202 


Diagnosis 


. 591 


Causes 


202 


Causes . 


591 


Nature 


. 202 


Prognosis 


. 592 


Prognosis 


203 


Treatment . 


592 


Treatment 


. 203 


Eye, Diseases of 


. 568 


Glossitis 


338 



698 



INDEX. 



Glossitis. 


PAOE 


Hemorrhage, Gastric . 


PANE 

524 


Causes 


. 338 


Hemorrhage, Intestinal . 


. 526 


Treatment . 


338 


Hemorrhage, Nasal 


523 


Goitre. See Bronchocele 


. 566 


Hemorrhage, Pulmonary 


. 530 


Gonorrhoea 


663 


Hemorrhage, Renal 


528 


Symptoms 


. 664 


Hemorrhage, Uterine 


. 534 


in women 


665 


Hemorrhoids, (Piles) . 


412 


Treatment 


. 665 


Symptoms 


. 414 


Gout, (Arthritis) 


216 


Diagnosis 


415 


Symptoms 


. 216 


Causes .... 


. 415 


of chronic 


217 


Treatment . 


415 


Anatomical characters 


. 218 


Hepatitis, Acute 


. 372 


Diagnosis 


219 


Symptoms . 


373 


Causes 


. 219 


Anatomical characters 


. 374 


Pathology . 


219 


Diagnosis 


374 


Prognosis 


. 222 


Causes .... 


. 375 


Treatment . 


222 


Pathology 


375 


Granular Disease of the Kidne 


y . 630 


Treatment 


. 376 


Gravel. See Lithiasis 


643 


Hepatitis, Chronic 


377 






Symptoms 


. 377 


Hsematemesis . 


. 524 


Anatomical characters 


377 


Symptoms . 


524 


Causes .... 


. 378 


Diagnosis 


. 525 


Treatment . 


378 


Causes 


525 


Herpes. See Vesicular Eruption 


s . 611 


Anatomical characters 


. 525 


Hiccough. See Singultus . 


332 


Prognosis 


525 


Hooping-cough, (Pertussis) 


. 461 


Treatment 


. 525 


Symptoms . 


461 


Heematuria 


528 


Prognosis 


. 462 


Symptoms 


. 528 


Cause 


462 


Diagnosis 


529 


Anatomical characters 


. 462 


Causes . 


. 529 


Nature 


462 


Prognosis 


529 


Treatment 


. 463 


Treatment 


. 530 


Hydrophobia, ( Canine Rabies) 


321 


Haemoptysis 


530 


Symptoms 


. 321 


Symptoms , 


. 530 


Anatomical characters 


322 


Diagnosis 


532 


Diagnosis 


. 322 


Anatomical characters 


. 532 


Causes . . . 


322 


Causes 


532 


Nature . . , 


. 323 


Prognosis 


. 533 


Prognosis . 


324 


Treatment . 


533 


Treatment 


. 324 


Headache. See Cephalalgia 


224 


Hydrops, {Dropsy) 


543 


Heart, Auscultation of 


. ' 481 


Symptoms 


. 544 


Heart, Dilatation of 


. 501 


Causes . 


545 


Heart, Hypertrophy of 


500 


Morbid appearances 


. 545 


Heart, Inflammation of . 


. 496 


Prognosis . 


545 


Heart, Neuralgia of . 


511 


Treatment 


. 546 


Heart, Organic Disease of 


. 498 


Hydrothorax . . 


552 


Heart, Percussion of . 


488 


Symptoms 


. 552 


Heart, Rupture of . 


. 505 


Diagnosis . . 


553 


Heart, Sympathetic Affections 


of 506 


Causes . . 


. 554 


Heat, a Cause of Disease 


. 27 


Prognosis . 


554 


Hemiplegia 


262 


Treatment 


. 554 


Hemorrhage . 


. 520 


Hydrocephalus . 


557 


Active 


520 


Symptoms 


. 557 


Passive 


. 520 


Anatomical characters 


559 


Symptoms . 


521 


Diagnosis 


. 559 


of Active . 


. 521 


Causes . 


560 


of Passive 


521 


Prognosis 


. 560 


Causes 


. 521 


Treatment . 


560 


Prognosis 


522 


Hydropericardium . 


. 555 


Treatment 


. 522 


Symptoms . 


555 





INDEX. 


Guy 




PAGE 




PAGE 


Hydroperieardium. 




Intermittent Fever. 




Diagnosis 


. 556 


The Malignant . 


96 


Morbid appearances 


556 


Irregularities . 


. 96 


Prognosis 


. 556 


Effects of Ague 


96 


Treatment . 


557 


Prognosis 


. 97 


Hypertrophy of the Heart 


. 500 


Causes 


97 


Hysteria .... 


308 


Proximate cause 


. 98 


Symptoms 


. 309 


Treatment . 


99 


Anatomical characters 


310 


Internal Otitis 


. 593 


Causes 


. 311 


Symptoms . 


593 


Pathology . 


311 


Diagnosis 


. 594 


Diagnosis 


. 311 


Causes 


594 


Prognosis 


312 


Prognosis 


. 594 


Treatment 


. 312 


Treatment . 


594 






Intestinal Hemorrhage . 


. 526 


Icterus. See Jaundice 


416 


Symptoms . 


527 


Icthyosis. See Scaly Eruptions . 617 


Anatomical charactei 


-s . . 527 


Idio-miasmata, a cause of di 


sease 32 


Causes 


527 


Idiotism, Insanity . 


. 290 


Prognosis 


. 527 


Impetigo. See Pustular Er 


uptions 614 


Treatment . 


528 


Incontinence of Urine 


. 654 


Intestinal Worms 


. 408 


Symptoms . 


654 


Symptoms . 


409 


Causes 


. 655 


Treatment 


. 410 


Treatment . 


655 


Intestines, Cancer of . 


. < 366 


Indications of Treatment in 


Disease 47 


Intoxicating Liquors, a c 


ause of dis- 


Indigestion. See Dyspepsia 


381 


ease 


. 27 


Inflammation . 


. 57 


Intussusception . 


405 


Symptoms or phenomei] 


a . 57 


Symptoms 


. 405 


Diagnosis 


. 59 


Diagnosis 


405 


Causes 


60 


Causes 


. 405 


Morbid appearances 


. 60 


Prognosis 


406 


Nature 


61 


Nature 


. 406 


Theory of information 


. 62 


Treatment . 


406 


Terminations 


63 


Iris, Inflammation of 


. 580 


Modifications of 


. 64 


Iritis .... 


580 


Varieties of 


65 


Symptoms 


. 581 


Treatment of . 


. 65 


Diagnosis 


582 


Insanity 


283 


Causes 


. . .582 


Mania 


. 285 


Prognosis 


582 


Symptoms 


285 


Treatment 


. 583 


Monomania 


. 286 


Irrespirable Gases, Apna 


a from 475 


Symptoms 


286 


Irritation 


. 51 


of Hypochondria 


, 286 


Active or Sthenic 


51 


of Fanaticism 


287 


Passive or Asthenic 


. 52 


of Melancholy . 


. 287 


Local irritation 


52 


of Misanthropy 


288 


Nature of irritation 


. 53 


of Insane Impulse 


. 288 


Causes of 


53 


Dementia 


288 


Treatment 


. 54 


Moral Insanity 


. 289 


Irritation, Spinal 


313 


Idiotism 


290 


Itch. See Animalcular 1 


]ruptions 620 


Anatomical characters 


. 290 






Causes 


291 


Jaundice, {Icterus) . 


. 416 


Pathology 


. 293 


Symptoms . 


417 


Diagnosis 


294 


Anatomical characte 


ps . , 417 


Prognosis 


. 295 


Causes 


418 


Treatment . 


296 


Prognosis 


. 418 


Intermittent Fever 


. 94 


Treatment . 


418 


Complications 


95 






The Inflammatory . 


. 95 


Kidneys, Bright's Disease 


of . . 630 


The Congestive . 


96 


Kidneys, Granular diseas 


e of . 630 


The Gastric 


. 96 


Kidneys, Inflammation of 


. 626 



700 



INDEX, 



Kidneys, Neuralgia of 


PAGE 

634 


Malignant Dysentery. 


PAGE 


Koino-miasmata, a cause of disease 


31 


Diagnosis .... 


364 






Causes .... 


. 364 


Laryngitis .... 


. 444 


Pathology .... 


365 


Symptoms .... 


444 


Prognosis , . , 


. 365 


Anatomical characters 


. 445 


Treatment .... 


365 


Causes .... 


445 


Mania, Insanity 

Mania-a-potu, (Delirium Tremens) 


. 285 


Treatment 


. 446 


298 


Laryngo-tracheitis, (Croup) 


449 


Symptoms 


. 298 


Symptoms 


. 450 


Diagnosis .... 


300 


Diagnosis .... 


451 


Anatomical characters 


. 300 


Anatomical characters 


. 451 


Causes .... 


300 


Causes . . 


451 


Pathology 


. 302 


Prognosis 


. 451 


Prognosis .... 


302 


Treatment .... 


451 


Treatment 


. 302 


Larynx, Inflammation of 


. 444 


Materia Medica .... 


49 


Lead Colic 


401 


Measles. See Rubeola . 


. 175 


Symptoms 


. 401 


Meningitis ..... 


226 


Diagnosis .... 


402 


Symptoms 


. 227 


Anatomical characters 


. 402 


Anatomical characters 


231 


Cause 


403 


Diagnosis 


. 232 


Pathology 


403 


Causes .... 


233 


Prognosis .... 


404 


Treatment 


. 234 


Treatment 


404 


Meningitis, Cerebro-spinal . 


250 


Lepra. See Scaly Eruptions 


617 


Meningitis, Spinal . 


. 244 


Leucorrhoea .... 


680 


Meningitis, Tuberculous 


240 


Symptoms .... 


681 


Menses, Retention and Suppression of 684 


Causes 


681 


Menstruation, Painful or Difficult 


688 


Diagnosis .... 


682 


Metritis, Chronic 


675 


Prognosis . . . . 


682 


Symptoms .... 


676 


Treatment .... 


682 


Diagnosis .... 


676 


Licentiousness, a cause of disease . 


26 


Causes .... 


676 


Lichen. See Palpular Eruptions 


609 


Treatment 


676 


Light, a cause of disease 


29 


Metroperitonitis .... 


670 


Lithiasis, ( Gravel) 


643 


Symptoms .... 


671 


Symptoms . 


644 


Anatomical characters 


672 


of Renal 


644 


Causes 


673 


of the Ureters . 


644 


Treatment .... 


674 


of Vesical 


644 


Metrorrhagia, ( Uterine Hemorrhage) 


534 


of Urethral 


644 


Symptoms .... 


534 


of the Lithic Acid Diathesis 


644 


Causes .... 


535 


of the Phosphatic Diathesis 


645 


Prognosis .... 


536 


of the Oxalatic Diathesis 


646 


Treatment .... 


536 


Diagnosis . 


646 


Mineral Poisons, a cause of disease 


30 


Causes .... 


647 


Monomania, Insanity 


286 


Prognosis . 


648 


Moral Insanity .... 


289 


Treatment .... 


649 


Mucous Enteritis .... 


356 


Locked-jaw. See Tetanus 


315 


Symptoms .... 


357 


Lungs, Inflammation of 


432 


of Chronic 


357 






Anatomical characters 


358 


Malignant Cholera . 


390 


Diagnosis . . . 


358 


Symptoms .... 


390 


Causes .... 


358 


Anatomical characters 


391 


Treatment .... 


358 


Diagnosis .... 


392 


Mumps. See Parotitis 


344 


Causes 


392 


Myelitis 


247 


Nature .... 


392 


Symptoms .... 


248 


Prognosis . 


393 


Anatomical characters 


249 


Treatment .... 


393 


Diagnosis .... 


249 


Malignant Dysentery 


363 


Causes 


249 


Symptoms .... 


364 


Pathology .... 


250 


Anatomical characters 


364 1 


Prognosis .... 


250 



INDEX. 



701 



Myelitis. 


PAGE 


(Esophagitis . , 


PAGE 

. 345 


Treatment . 


250 


Symptoms . 


345 






Causes 


. 346 


Nature of Disease . 


. 17 


Treatment . 


346 


Nephralgia 


634 


Ophthalmia, Catarrhal 


. ■ .568 


Symptoms 


. 634 


Ophthalmia, Purulent 


571 


Diagnosis 


634 


Ophthalmia, Rheumatic 


. 576 


Causes 


. 634 


Ophthalmia, Scrofulous 


574 


Treatment . 


634 


Organic Diseases of the I 


[eart . 498 


Nephritis 


. 626 


General Symptoms 


498 


Symptoms . 


628 


Diagnosis 


. 499 


Diagnosis 


. 629 


Causes 


500 


Causes 


629 


Prognosis 


. 500 


Morbid appearances 


. 629 


Hypertrophy 


500 


Treatment . 


629 


Symptoms 


. 500 


Nervous Deafness . 


. 598 


Diagnosis 


501 


Symptoms . 


599 


Dilatation 


. 501 


Diagnosis . , 


. 599 


Symptoms 


502 


Causes 


600 


Disease of the Valve 


s . .502 


Prognosis 


. 600 


Symptoms 


503 


Treatment . 


600 


Aneurism of the Aor 


ta . . 504 


Nervous System, Disease of 


224 


Symptoms 


504 


Nervous System, Symptoms 


develop- 


Diagnosis 


. 504 


ed by 


35 


Rupture of the Hear 


t . . 505 


Nettle Rash . 


. 608 


Symptoms 


. 505 


Symptoms . 


608 


Treatment, general 


505 


Diagnosis 


. 608 


of Hypertrophy 


. 505 


Causes 


608 


of Dilatation 


506 


Nature 


. 609 


of Disease of the 


Valves . 506 


Treatment . 


609 


Otalgia, {Ear-ache) 


597 


Neuralgia of the Heart . 


. 511 


Symptoms 


. 597 


Symptoms . 


511 


Diagnosis 


598 


Causes 


. 511 


Causes 


. 598 


Pathology . 
Prognosis 


511 


Treatment . 


598 


. 512 


Otitis, External 


. 590 


Treatment . 


512 


Otitis, General 


586 


Neuralgia 


. 325 


Otitis, Internal 


. 593 


Symptoms . 


325 


Otorrhcea . 


595 


of the Head 


. 326 


Symptoms 


. 596 


of the Face . 


326 


Causes 


596 


of the Optic Nerve 


. 326 


Treatment 


. 596 


of the Arms . 


326 






of the Intercostal 1 


Serves . 326 


Palsy. See Paralysis 


. 261 


of the Breasts 


326 


Papular Eruptions 


609 


of the Abdominal I 


Muscles 326 


Symptoms 


. 610 


of the Lower Extre 


mities . 327 


Diagnosis 


610 


of the Larynx or L 


ungs 327 


Causes 


. ' . 610 


of the Heart 


. 327 


Nature 


610 


of the Stomach 


327 


Treatment 


. 611 


of the Liver 


. 327 


Paralysis . . « 


261 


of the Kidneys 


327 


Hemiplegia 


. 262 


of the Uterus 


. 327 


Symptoms 


262 


of the Testicles 


327 


Treatment 


. 263 


of the Bladder . 


. 327 


Paraplegia . 


264 


of the Rectum 


328 


Symptoms 


. 264 


of the Spine 


. 328 


Causes . 


264 


Anatomical characters 


328 


Prognosis . 


. 265 


Diagnosis 


. 328 


Treatment 


265 


Causes 


328 


Paralysis Partialis . 


. 267 


Nature 


. 329 


Causes . 


267 


Treatment . . 


329 


Treatment 


. 268 



702 



INDEX. 





PAGE 




PAGE 


Paralysis Partialis 


267 


Plague 


. 148 


Paraplegia, Paralysis 


. 264 


Symptoms .... 


148 


Parasites, a cause of disease 


30 


Diagnosis 


. 150 


Parotitis, (Mumps) . 


. 344 


Anatomical characters 


151 


Symptoms .... 


344 


Cause .... 


. 151 


Causes .... 


. 344 


Nature 


152 


Treatment .... 


344 


Prognosis 


. 153 


Pathology of Fever . 


. 67 


Treatment . 


153 


Idiopathic Fevers 


67 


Pleurisy. See Pleuritis . 


. 428 


Symptomatic Fevers 


. 74 


Pleuritis, (Pleurisy) . 


428 


Pemphigus. See Vesicular Eruptions 611 


Symptoms 


. 429 


Percussion and Auscultation . 


. 420 


Causes 


430 


Pericarditis .... 


488 


Anatomical characters 


. 431 


Symptoms 


. 489 


Diagnosis 


431 


Anatomical characters 


490 


Prognosis 


. 431 


Diagnosis 


. 491 


Treatment . 


431 


Causes .... 


491 


Pneunonia, (Pneumonitis) 


. 432 


Prognosis 


. 491 


Symptoms . 


433 


Treatment .... 


492 


Anatomical characters 


. 435 


Pericardium, Inflammation of 


. 488 


Diagnosis 


436 


Peritoneal Enteritis 


354 


Prognosis 


. 436 


Symptoms 


. 354 


Causes 


436 


Diagnosis .... 


354 


Treatment 


. 436 


Anatomical characters 


. 355 


Pneumonia, Bilious 


438 


Causes .... 


355 


Pneumonitis. See Pneumonia 


. 432 


Prognosis 


. 355 


Pneumothrax 


478 


Treatment .... 


355 


Symptoms 


. 478 


Peritonitis, Acute . 


. 367 


Diagnosis 


478 


Symptoms .... 


367 


Causes .... 


. 479 


Diagnosis . 


. 368 


Treatment 


479 


Anatomical characters 


368 


Pox. See Syphilis 


. 666 


Causes '. 


. 369 


Prurigo. See Papular Eruptions 609 


Treatment .... 


369 


Psoriasis. See Scaly Eruptions 


617 


Peritonitis, Chronic 


. 370 


Puerperal Fever. See Metroperitonitis 670 


Symptoms .... 


370 


Purpura .... 


197 


Anatomical characters 


. 371 


Symptoms 


. 197 


Causes .... 


371 


Diagnosis 


198 


Treatment 


. 371 


Anatomical characters 


. 199 


Peritonitis, Puerperal 


670 


Causes 


199 


Pertussis. See Hooping Cough 


. 461 


Pathology 


. 199 


Pharyngitis, (Sore-throat) . 


339 


Prognosis 


199 


Symptoms 


. 339 


Treatment 


. 200 


of simple 


339 


Purulent Ophthalmia 


571 


of pseudo-membranous 


. 340 


Symptoms 


. 571 


of ulcerative 


340 


Diagnosis 


572 


of gangrenous . 


. 340 


Causes 


. 572 


Diagnosis . . 


340 


Prognosis 


572 


Causes . . . 


. 341 


Treatment 


. 572 


Treatment .... 


341 


Pustular Eruptions 


614 


Phenomena of Fever 


. 86 


Symptoms 


. 615 


Phlebitis 


516 


Diagnosis 


615 


Symptoms 


. 516 


Causes .... 


. 615 


Diagnosis .... 


517 


Nature 


616 


Anatomical characters 


. 517 


Treatment 


. 616 


Causes .... 

Prognosis 


517 

. 518 


Quinsy. See Tonsillitis 


342 


Treatment .... 


518 


Rashes and Eruptions 


. 601 


Phlebitis, Crural 


. 518 


Symptoms . . 


603 


Phthisis, Tubercular . 


463 


Diagnosis 


. 604 


Piles. See Hemorrhoids 


. 412 


Causes 


604 


Pityriasis. See Scaly Eruptions 


617 


Nature .... 


. 604 



INDEX. 



703 





PAGE 


1 


PAGE 


Rashes and Eruptions. 




Scarlatina, [Scarlet Fever) . 


180 


Treatment . 


604 


Symptoms 


. 180 


Rash, Xettle . 


. 608 


of the Simple 


180 


Rash, Red .... 


605 


of the Anginose 


. 181 


Rash, Rose . 


. 606 


of the Malignant . 


181 


Rattles. See Tracheitis 


447 


Sequelas .... 


. 182 


Red Rash . 


. 605 


Diagnosis 


182 


Diagnosis 


606 


Anatomical characters 


. 183 


Causes . 


. 606 


Cause .... 


183 


Treatment . 


606 


Pathology 
Prognosis 


. 183 


Respiratory System, Disease of 


. 420 


184 


Respiratory System. Symptom 


s de- 


Treatment 


. 184 


veloped by . 


38 


Scarlet Fever. See Scarlatina 


180 


Retention of Urine . 


652 


Scorbutus, [Scurvy) 


. 537 


Symptoms 


. 652 


Symptoms . 


538 


Diagnosis 


652 


Anatomical characters 


. 538 


Causes . . . 


. 653 


Diagnosis 


539 


Treatment . 


653 


Causes . . • 


. 539 


Rheumatism, Acute 


. 206 


Prognosis . 


539 


Symptoms . 


206 


Pathology 


. 539 


Anatomical characters 


. 208 


Treatment . 


539 


Causes 


208 


Scrofula 


. 561 


Diagnosis 


. 209 


Symptoms . 


562 


Prognosis 


210 


Anatomical characters 


. 563 


Treatment 


. 210 


Diagnosis . . . . 


563 


Rheumatism, Chronic 


212 


Causes .... 


. 563 


Symptoms 


. 212 


Pathology . . . . 


564 


Diagnosis 


213 


Treatment 


. 565 


Causes .... 


. 213 


Scrofulous Ophthalmia 


574 


Pathology 


213 


Symptoms 


. 574 


Prognosis 


. 214 


Diagnosis . 


575 


Treatment . 


215 


Causes .... 


. 575 


Rheumatic Ophthalmia . 


. 576 


Prognosis . 


575 


Symptoms . 


577 


Treatment 


. 575 


Diagnosis 


.577 


Scurvy. See Scorbutus 


537 


Causes 


577 


Simple Continued Fever . 


. Ill 


Prognosis 


. 577 


Symptoms . 


111 


Treatment 


. 578 


Causes .... 


. 113 


Rose Rash, [Roseola) . 


606 


Pathology . 


116 


Symptoms 


. 607 


Prognosis 


. 117 


Diagnosis 


607 


Treatment . 


117 


Causes .... 


. 607 


Singultus, [Hiccough) 


. 332 


Treatment . 


607 


Symptoms . . . 


332 


Roseola. See Rose Rash 


. 606 


Causes .... 


. 333 


Rubeola, [Measles) 


175 


* Treatment . . . . 


333 


Symptoms 


. 175 


Skin, Diseases of 


. 601 


Sequelae 


177 


Skin, Symptoms developed by 


40 


Diagnosis 


. 177 


Small-pox. See Variola 


. 162 


Anatomical characters 


178 


Sore Mouth. See Stomatitis 


334 


Causes .... 


. 178 


Sore Throat. See Pharyngitis 


. 339 


Prognosis 


178 


Spermatorrhoea . . . . 


656 


Treatment 


. 179 


Symptoms 


. 659 


Rupia. See Vesicular Eruption 


i 611 


Causes . . . . 


660 


Rupture of the Heart 


. 505 


Pathology 


, 660 






Diagnosis . 


661 


Scaly Eruptions . 


617 


Prognosis 


. 662 


Symptoms 


. 617 


Treatment . 


662 


Diagnosis 


618 


Spinal Cord, Inflammation of . 


. 247 


Causes .... 


. 618 


Spinal Irritation 


313 


Nature 


618 


Symptoms 


. 313 


Treatment . . 


. 619* 


Diagnosis . 


314 



704 



INDEX. 



Spinal Irritation. 




Symptoms of Disease, developed 


Causes .... 


. 314 


By the Skin 


Nature 


315 


By the Urinary Organs . 


Prognosis 


. 315 


By the Genital Organs 


Treatment . 


315 


Syncope, (Fainting) 


Spinal Meningitis . 


. 244 


Symptoms .... 


Symptoms . 


245 


Diagnosis . . . 


Anatomical characters 


. 246 


Causes .... 


Diagnosis 


246 


Prognosis . 


Causes .... 


. 246 


Treatment .... 


Prognosis 


246 


Syphilis ...... 


Treatment 


. 246 


Symptoms .... 


Spleen, Inflammation of 


379 


Diagnosis . 


Splenitis .... 


. 379 


of Indurated Chancre . 


Symptoms . 


379 


of Simple . 


of Chronic 


. 380 


of the Irritable 


Anatomical characters 


380 


of the Inflamed . 


Diagnosis 


. 380 


of the Sloughing . 


Causes . . 


380 


Treatment . . . . 


Treatment 


. 380 




St. Vitus's Dance, See Chorea 


280 


Tetanus, (Locked-jaw) 


Stomach, Acute Inflammation of 


. 346 


Symptoms . 


Stomach, Chronic Inflammation c 


f 349 


Anatomical characters 


Stomach, Cancer of 


. 351 


Diagnosis . . . . 


Stomatitis. (Sore Mouth) . 


334 


Causes .... 


Symptoms 


. 334 


Pathology . . . 


of Thrush . 


335 


Prognosis .... 


of Follicular 


. 335 


Treatment . . . . 


of Apthous . 


335 


Tobacco, a cause of disease 


of Ulcerative 


. 335 


Tongue, Inflammation of 


of Nursing . 


335 


Tonsillitis, (Quinsy) . 


of Gangrenous . 


. 335 


Symptoms . 


of Mercurial . 


335 


Causes .... 


Causes .... 


. 336 


Treatment . . . . 


Treatment . 


336 


Trachea, Inflammation of . 


Stone in the Bladder. See Lithi 


asis 643 


Tracheitis, (Rattles) 


Strangury. See Dysuria 


. 653 


Symptoms .... 


Strangulation, Apnoea from 


474 


Anatomical characters 


Strophulus. See Papular Erupti 
Suppression of the Menses 


ons 609 


Diagnosis .... 


. 684 


Causes 


Suppression of Urine . 


650 


Treatment .... 


Symptoms 


. 650 


Treatment of Disease 


Causes 


651 


Indications .... 


Treatment 


. 651 


for Depletion 


Sycosis. See Cryptogamous Erupt 
Sympathetic Affections of the lh 


ions 621 


for Repletion 


-art 506 


for Dilution 


Symptoms 


. 507 


for Stimulation 


Diagnosis 


507 


for Sedation 


Causes .... 


. 508 


for Revulsion 


Tobacco 


508 


for Suppression 


Intoxicating Liquors 


. 509 


for Alteration 


Spinal Irritation . 


509 


for Chemical Action . 


Prognosis 


. 509 


for Mechanical Influence 


Treatment . 


509 


Materia Medica 


Symptoms of Disease, developed 


. 34 


Prescriptions 


By the Nervous System 


35 


Quiet 


By the Digestive System . 


. 37 


Nourishment 


By the Respiratory System 


38 


Trychosis. See Cryptogamous Erup- 


By the Circulatory Svstem 


. 38 


tions 


By the Eye . " . 


39 


Tubercular Phthisis, ( Consumption) 


By the Ear 


. 40 


Symptoms . . . . 



INDEX. 



705 



Tubercular Phthisis. 




Varicella. 




Symptoms of Laryngeal 


464 


Symptoms .... 


174 


of Pulmonary . 


465 


Diagnosis .• . . . 


174 


Anatomical characters 


467 


Causes .... 


175 


Diagnosis . 


467 


Treatment . 


175 


Causes .... 


468 


Variola, (Small-pox) . 


162 


Prognosis 


468 


Symptoms . 


162 


Treatment .... 


469 


of the Distinct 


162 


Tuberculous Meningitis . 


240 


of the Confluent 


164 


Symptoms .... 


240 


of the Varioloid 


165 


Anatomical characters 


241 


Sequelae 


166 


Diagnosis .... 


242 


Anatomical characters 


166 


Causes .... 


242 


Cause 


166 


Pathology .... 


243 


Pathology .... 
Diagnosis . 


167 


Prognosis 


243 


167 


Treatment .... 


243 


Prognosis .... 


168 


Typhus Continued Fever 


129 


Treatment . 


168 


Symptoms .... 


129 


Vegetable Poisons a cause of disease 


30 


Varieties 


131 


Veins, Inflammation of . 


516 


Diagnosis .... 


132 


Vesicular Eruptions . 


611 


Anatomical characters 


133 


Symptoms . . . . 


612 


Causes .... 


133 


Diagnosis .... 


613 


Nature .... 


134 


Causes 


613 


Prognosis .... 


135 


Nature .... 


613 


Treatment 


135 


Treatment 


613 


Urinary Organs, Disease of 


626 


Water, a cause of disease 


28 


Urinary Organs, Symptoms develop 




Whites. See Leucorrhoea 


680 


ed by . 


41 


Womb, Acute Inflammation of . 


670 


Urine, Difficulty in Voiding 


653 


Womb, Chronic Inflammation of 


675 


Urine, Incontinuance of . 


. 654 


Womb, Disease of the Neck of . 


677 


Urine, Retention of 


652 


Worms, Intestinal . 


408 


Urine, Suppression of 


650 


Symptoms of 


409 


Uticaria. See Nettle Rash 


608 


Treatment for . 


410 


Uterus, Acute Inflammation of 


670 






Uterus, Chronic Inflammation of 


675 


Yellow Fever .... 


138 


Uterus, Disease of the Neck of 


677 


Symptoms 


139 






Diagnosis .... 


141 


Vaccina, [Cow-pox) 


171 


Anatomical characters 


141 


Symptoms 


. 171 


Causes .... 


142 


Diagnosis .... 


173 


Nature 


144 


Prognosis 


173 


Prognosis .... 


145 


Treatment .... 


173 


Treatment . 


146 


Varicella, (Chicken-pox) . 


174 







45 



